Autografting tool with enhanced flute profile and methods of use

ABSTRACT

Tools and methods for expanding a precursor hole in a host material to receive a fixture. The precursor hole is enlarged by a rotary tool having helical flutes and interposed lands. The flutes have a negative rake angle. The lands each have a working edge that cuts the host material when the tool is rotated in a cutting direction, and that condenses the host material when the tool is rotated in a densifying direction. The body of the rotary tool has a stopper section that plugs the hole when a certain depth is reached. When the tool is used with a copious wash of irrigating fluid at or below the necessary depth, hydraulic pressure builds inside the precursor hole. The hydraulic pressure can be advantageously exploited in cutting mode to autograft a slurry of host material particles into the sidewalls of the hole and create an incipient densifying crust.

BACKGROUND OF THE INVENTION Field of the Invention

The invention relates generally to tools for preparing a hole to receivean implant or fixture, and more particularly to rotary osteotomes andmethods implemented thereby for expanding an osteotomy or hole in aninorganic material to receive an implant or other fixation device.

Description of Related Art

An implant is a medical device manufactured to replace a missingbiological structure, to support a damaged biological structure, or toenhance an existing biological structure. Bone implants are implants ofthe type placed into the bone of a patient. Bone implants may be foundthroughout the human skeletal system, including dental implants in a jawbone to replace a lost or damaged tooth, joint implants to replace adamaged joint such as in hips and knees, and reinforcement implantsinstalled to repair fractures and remediate other deficiencies likepedicle screws used in spinal stabilization, to name but a few. Theplacement of an implant often requires a preparation into the bone usingeither hand osteotomes or precision drills with highly regulated speedto prevent burning or pressure necrosis of the bone. After a variableamount of time to allow the bone to grow onto the surface of theimplant, sufficient healing will enable a patient to startrehabilitation therapy or return to normal use or perhaps the placementof a restoration or other attachment feature.

There are several known ways to form a receiving hole or osteotomy.Since the early days of implantology, for example, osteotomies have beenprepared using standard drills that look and handle much like drillsdesigned for use in industrial applications. These drill designs haveproven to be functional for dental and medical applications, howevernoticeably imperfect. Implant success rates have been satisfactory overtime but osteotomy preparation techniques have still been lacking forvarious reasons. Standard drill designs used in dental and medicalimplantology are made to excavate bone to create room for the implant tobe placed, just like a drill designed for non-medical applications.Standard drill designs, in twist or fluted shapes, cut bone effectivelybut typically do not produce a clean, precise circumferential osteotomy.Osteotomies may become elongated and elliptical due to chatter becausethe drills are very aggressive cutters. In circumstances where theosteotomy is imperfectly round, the implant insertion torque may bereduced, leading to poor primary stability and potential lack ofintegration. Osteotomies drilled into narrow bone locations may producedehiscence, buccally or lingually, which also reduces primary stabilityand will require an additional bone grafting procedure, which adds costand healing time to treatment.

More recently, a novel biomechanical bone preparation technique called“osseodensification” has been pioneered by the Applicant of thisinvention. The osseodensification technique is based on the preservationof host bone, and has gained rapid acceptance in the dental community.In some instances, osseodensification is considered a preferred standardof care. Examples of osseodensification can be seen in U.S. Pat. No.9,028,253, issued May 12, 2015, and in U.S. Pat. No. 9,326,778, issuedMay 3, 2016, and PCT Publication No. WO 2015/138842, published Sep. 17,2015. The entire disclosures of these references are hereby incorporatedby reference and relied upon to the extent permitted by the relevantnational jurisdiction.

Generally described, osseodensification is a procedure for enlarging anosteotomy using a specially-designed, multi-fluted, rotary osteotome, orbur. An example of a suitable rotary osteotome is described in theabove-mentioned U.S. Pat. No. 9,326,778. Rotary osteotomes for dentalapplications are marketed as Densah® Burs through Versah, LLC ofJackson, Mich. USA, a licensee of the Applicant.

Unlike traditional drilling techniques, osseodensification does notexcavate bone tissue. Rather, bone tissue is simultaneously compactedand auto-grafted in outwardly expanding directions from the osteotomy,somewhat akin to a traditional hammered osteotome but without the traumaand other limitations of that technique. When rotated at high speed in areversed, non-cutting direction with steady external irrigation, theserotary osteotomes form a strong and dense layer of bone tissue along thewalls and base of the osteotomy. Dense compacted bone tissue producesstronger purchase for the surgeon's favorite implant and may facilitatefaster healing.

Briefly, an example of dental implantology may be used to illustrate thegeneral principles of the osseodensification technique. The osteotomysite is first prepared with a precursor pilot hole drilled with a small,e.g., 1.5 mm, standard medical-grade twist drill or other boring tool.(Of course, the circumstances of any given surgical application, whetherdental or non-dental in nature, will dictate the size of precursor pilothole and other characteristics of the operation.) The precursor pilothole is drilled to a predetermined depth. Using a rotary osteotomedesigned for osseodensification, the surgeon decides whether to enlargethe precursor pilot hole either by densifying or cutting, taking intoaccount situational factors which may include hardness of the bone,final intended osteotomy/implant size, local width of bone formation,and other relevant factors.

If the surgeon decides to enlarge the precursor pilot hole by cutting,the specially designed rotary osteotome is rotated in a cuttingdirection at high speed. High speed is defined as generally above 200RPM for rotary osteotomes in the range of about 1.5 mm to 6 mm indiameter. The rotary osteotome is advanced into the precursor pilothole, often with a gentle pumping motion and abundant irrigation. On itsdescent, the working edges of the rotary osteotome cut bone materialsinto small chips or particles, which accumulate in the flutes. The boneparticles are subsequently discarded or collected/harvested if desiredfor later use. The osteotomy can likewise be further enlarged by cutting(or densifying) in one or more subsequent operations using progressivelylarger rotary osteotomes.

On the other hand, if the surgeon prefers to enlarge the precursor pilothole by densifying, the same rotary osteotome is used but insteadrotated in a non-cutting direction at high speed. If the rotaryosteotome is designed so that its cutting direction is clockwise (as istypical with most twist drills), then the non-cutting direction for thatsame rotary osteotome would be counter-clockwise. I.e., the non-cuttingor densifying direction is the reverse of the cutting direction. Whendensifying, the surgeon advances the counter-spinning rotary osteotomeinto the precursor pilot hole (or a precursor hole formed by a previousexpansion operation like that described in the preceding paragraph),together with copious irrigation. Downward pressure applied by thesurgeon is needed to keep the working edges of the rotary osteotome incontact with the bone surface inside the osteotomy, often with theabove-mentioned gentle bouncing motion to modulate the pressure andthereby avoid over-heating and over-straining of bone tissue. The harderthe surgeon pushes the rotary osteotome into the osteotomy, the morepressure is exerted laterally, both mechanically and throughhydrodynamic effects enabled by the concurrent irrigation. Care is takento maintain alignment between the longitudinal axis of the rotaryosteotome and the bore axis of the osteotomy at all times. Once therotary osteotome has reached the full intended depth, enlargement withthat rotary osteotome is complete. The osteotomy can then be furtherenlarged by densifying with one or more subsequent operations usingprogressively larger rotary osteotomes following the same procedures.

Biomechanical as well as histological validation studies of theosseodensification technology have concluded that, in porcine tibia andSheep Illiac Crest, osseodensification facilitates bone expansion,increases implant stability and creates a densification layer around thepreparation site by compacting and autografting bone particles along theentire depth of the osteotomy.

Although described up to now in the context of medical applications,these same techniques are applicable to non-bone materials. Someindustrial applications, including those which require the placement ofscrewed anchors into foamed metals, cellular compositions, and othernon-organic materials, may be accepting of and benefit from the generalprinciples of this technology.

Osseodensification is a relatively new field. As with any emergingtechnology, new and improved tools and techniques are expected as thetechnology begins to mature and be perfected. Furthermore, there is acontinuing need to improve the efficiency of surgical operations to makethem faster and easier to perform. Therefore, any improvements inosseodensification tools and/or techniques that advances the basetechnology, and that improves efficiency, will be welcomed by therelevant medical and industrial communities.

BRIEF SUMMARY OF THE INVENTION

According to a first aspect of this invention, a rotary osteotomecomprises a shank that establishes a longitudinal axis of rotation. Abody extends from the shank. The body has an apical end that is remotefrom the shank. A plurality of helically spiraling flutes are disposedabout the body. Each flute has a cutting face on one side thereofdefining a rake angle and a densifying face on the other side thereofdefining a heel-side angle. The flutes have an axial length and radialdepth. A stopper section of the body is disposed between the flutes andthe shank. A land is formed between each adjacent pair of flutes. Eachthe land has a working edge along the cutting face of the one adjacentflute. The working edge helically twists about the body. The flutes areformed with a continuously negative rake angle along their full lengths.

The negative rake angles in combination with the stopper section enablethe rotary osteotome to achieve a heretofore unachievable effect, namelythe incipient formation of a densifying crust in the surroundingosteotomy (i.e., hole) while being operating in a cutting mode.

According to another aspect of this invention, a method for enlarging aprecursor hole in a host material is provided. The precursor hole isenlarged in preparation to receive a screw-in fixture with heightenedinitial stability. The method comprises a series of steps, which includemaking available a rotary tool configured to be turned at high speed ina cutting direction. The tool comprises a shank and a body joined to theshank. The body has an apical end remote from the shank. A plurality offlutes disposed about the body. The flutes has a helical twist. Eachflute has a densifying face and an opposing cutting face. A stoppersection of the body disposed between the flutes and the shank. The bodyalso has a plurality of lands. Each land is formed between two adjacentflutes. Each land has a land face joining a densifying face of one fluteand a cutting face of the other flute. Each land face intersects therespective the cutting face along a working edge. The steps furtherinclude irrigating a precursor hole in a host material. The precursorhole is of the type having an interior surface extending between agenerally circular entrance and a bottom closed by the host material.The steps include rotating the body of the tool in a cutting directiongreater than about 200 RPM. The cutting direction is defined asrotationally sweeping the cutting faces into the host material. Stepsteps furthermore include enlarging the precursor hole by forciblypushing the rotating body to the bottom of the precursor hole so thatthe working edges cut the host material and a slurry of host materialparticles mixed with irrigating liquid accumulates in the flutes. Thislatter step of enlarging the precursor hole includes concurrentlyplugging the hole with the stopper section of the body while continuingto apply axial force to pressurize the slurry thereby autografting(i.e., embedding) at least some of the host material particles that hadaccumulated in the flutes directly into the side walls of the hole.

The method of this invention enable formation of a hole in a cuttingmode possessing the early formation of a densifying crust within itsside walls to provide a later installed fixture to be screwed into thehole with a heightened initial stability.

These and other aspects of the invention will be understood more fullyby considering the detailed description and illustrations of thisinvention.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

These and other features and advantages of the present invention willbecome more readily appreciated when considered in connection with thefollowing detailed description and appended drawings, wherein:

FIG. 1 depicts an exemplary application of the present invention at anedentulous (without teeth) jaw site that needs expansion to receive animplant;

FIG. 2 is a view as in FIG. 1 , but showing the resulting fully preparedosteotomy as achieved through use of the present invention in aprogressive series of expansion steps;

FIG. 3 is a view as in FIG. 1 showing a progressive expansion step witha rotary osteotome according to one embodiment of this invention;

FIG. 4 is a view as in FIG. 2 in which an installed implant is poised toreceive an abutment or base for subsequent prosthetic (not shown);

FIG. 5 is a diagrammatic view illustrating by way of example the use ofa surgical kit containing four osteotomes of progressively largerdiameter according to the present invention in combination with areversible drill motor to concurrently prepare three separate osteotomysites in a human jaw using selective reversal of osteotome direction toenlarge each osteotomy either by cutting or burnishing without removingthe osteotome from the surgical drill motor;

FIG. 6 is a side elevation view of a rotary osteotome according to oneembodiment of this invention;

FIG. 7 is a simplified cross-sectional view showing a surgical procedurereferred to herein as “bounce” where an osteotome according to thepresent invention is repeatedly pushed into the osteotomy and withdrawnwhile the osteotome remains spinning in a repetitive manner so as toenlarge the osteotomy while enabling the surgeon to manage the expansionrate (and other factors) while making adjustments on-the-fly;

FIG. 8 is an exemplary graph plotting the force applied by a user toadvance the body into an osteotomy against the depth of penetration intothe osteotomy (or hole) in three separate procedures in order toillustrate that the surgeon (or user) can make on-the-fly adjustments tothe advancing force depending on particular situation;

FIG. 9 is a simplified stress-strain curve generally representative ofbone, metal foam and other host materials for with the present inventionis suited for use;

FIG. 10 is an enlarged view of the apical end of a rotary osteotomeaccording to one embodiment of this invention;

FIG. 11 depicts a cross-section through an osteotomy with a rotaryosteotome disposed partially within as in the midst of an expansionprocedure according to this invention;

FIG. 12 is an enlarged view of the area circumscribed at 12 in FIG. 11and enhanced with reaction forces (R) as applied by the walls of thebone to the rotary osteotome in response to rotation of the osteotome inthe burnishing direction;

FIG. 13 is a diagram of the reaction forces (R) of FIG. 12 , shownbroken into component lateral (R_(x)) and axial (R_(y)) forces;

FIG. 14 is a fragmentary perspective view of the apical end of a rotaryosteotome according to one embodiment of this invention;

FIG. 15 is an end view of the apical end of a rotary osteotome of FIGS.6, 10 and 14 ;

FIG. 15A is a cross-section of the apical end of an osteotome accordingto this invention taken generally along the semi-circular lines 15A-15Ain FIG. 15 ;

FIG. 16 is an enlarged view of a land as circumscribed at 16 in FIG. 15;

FIG. 17 is an exaggerated cross-section through an osteotomy with theapical end of a rotary osteotome shown at various stages of theexpansion procedure in order to describe the zones of an osteotomy thatexperience grinding, compaction and auto-grafting with each stage of theexpansion process;

FIG. 18 is a cross-sectional view taken generally along lines 18-18 inFIG. 17 ;

FIG. 19 is a cross-sectional view taken generally along lines 19-19 inFIG. 17 ;

FIG. 20 is an enlarged view of the area circumscribed at 20 in FIG. 17and depicting the bone grinding and auto-grafting features of the apicalend;

FIG. 21 is a fragmentary perspective view of the apical end as in FIG.14 but from a slightly different perspective and illustrating the regionof the apical end where bone material collects and is subsequentlyrepatriated into surrounding bone;

FIG. 22 is a micro-CT image showing a transverse slice through aPorcine03 medial tibial plateau with comparative holes created by aprior art burr drill and a rotary osteotome rotated in both cutting anddensifying directions;

FIGS. 23A-D are micro-CT images showing comparative axial slice views ofPorcine02 and Porcine03 medial tibial plateau holes created by a rotaryosteotome in both cutting and densifying directions;

FIG. 24 shows an alternative embodiment of the osteotome of thisinvention configured for high-frequency vibration rather than rotation;

FIG. 25 is a cross-section through an osteotomy with the alternativeosteotome of FIG. 24 disposed partially completing an expansionprocedure according to this invention;

FIG. 26 is an enlarged view of the apical end of the alternativeosteotome of FIG. 24 ;

FIG. 27 is a simplified depiction of a human skeleton highlighting someexamples of areas in which the novel osteotome of this invention mightbe effectively applied;

FIG. 27A is an enlarged view of a human vertebrae;

FIG. 27B is a view of the vertebrae as in FIG. 27A shown incross-section with a rotary osteotome according to one embodiment ofthis invention disposed to enlarge an osteotomy for the purpose ofreceiving a fixation screw or other implant device; and

FIG. 28 is a perspective view of a foam metal product having a holeformed therein using a rotary osteotome according to this inventionexemplifying at least one non-bone commercial application;

FIG. 29 is a cross-sectional view as in FIG. 7 showing osteotomeslightly raised out of contact with the inner sidewall of the osteotomywith irrigating fluid being forcefully propelled in-between the fluteslike a screw pump toward the bottom of the precursor hole, and depictinga generally uniform pressure gradient in the surrounding irrigatingfluid by the use of radiating arrows;

FIG. 30 is an enlarged view of the area circumscribed at 30 in FIG. 29showing the physical separation between the osteotome body and the innersidewall of the osteotomy;

FIG. 31 is a view as in FIG. 29 but showing osteotome pressed down intocontact with the inner sidewall of the osteotomy and the resultingchanges in pressure applied to the inner sidewall of the osteotomy;

FIG. 32 is a fragmentary cross-sectional view taken generally alonglines 32-32 of FIG. 31 showing the elevated hydrodynamic pressure spikegenerated against the bone sidewall immediately prior to contact with aworking edge;

FIG. 33 is a side elevation of an enhanced rotary osteotome according toan alternative embodiment of this invention;

FIG. 34 is a cross-sectional view taken helically along 34-34 in FIG. 33;

FIG. 35 is a cross-sectional view of the enhanced rotary osteotome astaken generally along lines 35-35 in FIG. 33 ;

FIG. 36 is partial cross-sectional view as in FIG. 34 but showing theflute formation in exaggerated form to emphasize various optionalattributes thereof;

FIG. 37 is simplified cross-sectional view of the enhanced rotaryosteotome as in FIG. 34 shown partially descending into a precursorosteotomy in the cutting mode;

FIG. 38 is a view as in FIG. 38 but showing the enhanced rotaryosteotome at full intended depth with its stopper section plugging theosteotomy so as to allow pressure build-up of the boney slurry trappedin the flutes;

FIG. 39 is a simplified flow diagram describing an optional methodreferred to as the Densify-After-Cut (DAC) protocol made possible bystructural configuration of the enhanced rotary osteotome;

FIG. 40 is an enlarged fragmentary of a flute region for the enhancedrotary osteotome of FIG. 38 as pressure builds in the boney slurry;

FIG. 41 is an enlargement of the area circumscribed at 41 in FIG. 40showing the relationship between the working edge and the osteotomysidewall after the pressure has induced a sufficiently strong strainresponse into the elastic or plastic range;

FIG. 42 is a side elevation of an enhanced rotary osteotome according toa slightly modified embodiment;

FIG. 43 is an apical end view as taken generally along lines 43-43 inFIG. 42 ;

FIG. 44 is a cross-sectional view as taken generally along lines 44-44in FIG. 42 ;

FIG. 45 is a cross-sectional view as taken generally along lines 45-45in FIG. 42 ;

FIG. 46 is a cross-sectional view as taken generally along lines 46-46in FIG. 42 ;

FIG. 47 is a cross-sectional view as taken generally along lines 47-47in FIG. 42 ; and

FIG. 48 is yet another alternative embodiment of the invention speciallyconfigured to produce a densifying crust while operated in the cuttingmode.

DETAILED DESCRIPTION OF THE INVENTION

Referring to the figures, wherein like numerals indicate like orcorresponding parts throughout the several views, FIGS. 1-4 show theexample of a dental implant, in which preparation of an osteotomy isrequired to receive a bone implant (FIG. 4 ). It will be understood thatthis invention is not limited to dental applications, but may be appliedacross a wide spectrum of orthopedic applications. Human applicationsare typical, but animal applications are equally plausible and notoutside the scope of this invention. Furthermore, the invention is noteven limited to bone applications, but may be used to prepare holes innon-organic materials for industrial and commercial applications,including but not limited to metal foam and other cellular materials toname but a few. In FIG. 1 , an edentulous (without teeth) jaw site 30 isshown that needs expanded and prepared as a final fully-formed osteotomy32 (FIG. 2 ) in order to receive an implant 34 (FIG. 4 ) or otherfixture device. A series of steps are required to accomplish thefully-formed osteotomy 32 of FIG. 2 . The series of steps include firstboring a pilot hole into the recipient bone to form the initialosteotomy (not shown), then incrementally expanding the osteotomy usingprogressively wider rotary expander devices or osteotomes, generallyindicated at 36, as shown in FIG. 3 , until a final intended diameter isachieved. Once the osteotomy has been prepared, the implant 34 orfixture screw is screwed into place as illustrated in FIG. 4 . Theprocedure of forming an osteotomy is described, generally, below.

FIG. 5 is a diagrammatic view illustrating by way of example the use ofa surgical kit containing four osteotomes 36A-D of progressively largerdiameter according to the present invention in combination with areversible surgical drill motor 38. The pilot drill is not shown in thisexample. The surgical kit may be used to concurrently prepare threeseparate osteotomy sites 32A, 32B and 32C, respectively, in a human jawbone 30 using the rotary osteotomes 36A-D and selectively reversingrotational direction to enlarge each osteotomy either by cutting orcompacting without removing a given osteotome 36 from the surgical drillmotor 38. Although the example is presented here again in the context ofa dental application, the described techniques are adaptable tonon-dental applications including, but not limited to, jointreplacement, bone fixations generally as well as inorganic industrialuses (see for examples FIGS. 27B and 28 ).

In the example of FIG. 5 , a first osteotomy site 32A is located in thefront of the mandible bone 30 where the bone width is relatively narrow.The composition of the bone 30 in the region of the first osteotomy site32A may be described as predominantly Type II, as an example. A secondosteotomy site 32B is located slightly posterior of the first site 32Ain a region of the mandible that has moderate bone 30 width. Thecomposition of the bone 30 in the region of the second osteotomy site32B may be described as generally a combination of Types II and III, inthis example. A third osteotomy site 32C is located in a molar region ofthe mandible and is surrounded by a relatively generous ridge width ofthe bone 30. The composition of the bone 30 in the region of the thirdosteotomy site 32C may be described as predominantly Type III in thisexample. Due to the varying ridge widths and compositions of bone 30 atsites 32A, 32B and 32C, the surgeon may not wish to apply the sameprotocol at each site. By using the present invention, a surgeon (oruser in non-surgical applications) has the ability to concurrentlyprepare all three osteotomy sites 32A-32C in different ways but usingthe same set of rotary osteotomes 36A-D in a highly efficient manner.

In this example, each osteotomy site 32A-32C is presumed to have aprecursor osteotomy prepared by first drilling a pilot hole of 1.5 mm.(Of course, the circumstances of any given surgical application, whetherdental or non-dental in nature, will dictate the size of precursor holeand other characteristics of the operation.) The precursor hole thatextends from an entrance 33 or rim in the exposed surface of the bone(or in the flesh if not previously resected) to a bottom 35. Theentrance 33 is identified in FIGS. 2 and 3 , whereas the bottom 35 isidentified in FIGS. 7 and 11 . The surgeon locks or otherwise installsthe first rotary osteotome 36A into the drill motor 38 and sets therotational direction to a non-cutting direction, which in this exampleis counter-clockwise as viewed from the top (i.e., the surgeon'sperspective). Although the surgeon may vary the rotational speed of theosteotome 36 according to the dictates of the situation, experimentalresults indicate that high rotation speeds, i.e., greater than about 200RPM, and torque settings between about 5-50 Ncm will providesatisfactory results. High speed rotation is considered anything aboveabout 200 RPM for rotary osteotome 36 diameters in the range of about1.5 mm to 6 mm. Upper ranges for these relatively small diameter rotaryosteotomes may reach about 2000 RPM. More preferably rotation speedsbetween about 600-1800 RPM and torque settings between about 20-45 Ncmprovide satisfactory results. And still more preferably, rotation speedsin the range of 800-1500 RPM and torque settings of about 35 Ncm providesatisfactory results. As the diameter of the osteotome 36 increases,however, it may be desirable to reduce the recommended rotationalspeeds. Speeds suggested here apply in context to the exemplary dentalapplications. Relatively large diameter rotary osteotomes 36 used forlarge-bone orthopedic applications like femurs may require slowerrotational speeds than rotary osteotomes 36 used for smaller boneapplications due to tangential velocity considerations at the workingedges. That is to say, as a guiding principle for large diameter rotaryosteotomes 36, it may be advantageous to maintain tangential velocity(as measured at the working edges 72) between about 0.02 m/s on the lowend and about 0.6 m/s on the high end to create a suitable compressionwave in the bone needed to accomplish osseodensification.

The surgeon pushes the rotating first osteotome 36A into the firstosteotomy site 32A to expand the initial pilot hole through compacting(the details of which are described in detail below). This is referredto as the densifying (non-cutting) mode of operation, and will bedescribed in technical terms below. However, due to the differentcompositional nature of the second 32B and third 32C osteotomy sites,the surgeon chooses to enlarge these other sites 32B, 32C by cuttingrather than compacting. To affect this, the surgeon reverses therotational direction of the drill motor 38 to clockwise without removingthe first osteotome 36A from the drill motor 38. High speed rotation isused in both densifying and cutting modes. Using a similar modulatedpushing motion, the surgeon enlarges the second 32B and third 32Costeotomy sites by removing bone material which may, if desired, beharvested. This is referred to as the cutting mode of operation, andwill be described further below. A continuous flow of irrigating fluidis used throughout the procedures.

At this stage in the hypothetical example, the first osteotomy site 32Ahas been expanded as much as the surgeon desires; no further expansionis needed of the first osteotomy site 32A, as the intention is to placea small-diameter implant in the first osteotomy site 32A. However, thesecond 32B and third 32C osteotomy sites both require additionalexpansion, as the intended implants for those sites have a largerdiameter. The surgeon then installs the second osteotome 36B into thedrill motor 38 and sets the rotational direction on the drill motor 38to counter-clockwise (non-cutting direction). The previously expandedholes in the second 32B and third 32C osteotomy sites are now consideredprecursor holes to the subsequent operations, each with an entrance 33in the exposed surface of the bone and a closed bottom 35. Skipping thecompleted first osteotomy site 32A, the surgeon then expands the secondosteotome 36B into the second osteotomy site 32B using the densifyingmode described above. Due to the different compositional nature of thethird osteotomy site 32C, however, the surgeon chooses to enlarge bycutting rather than compacting. To affect this, the surgeon changes therotational direction of the surgical motor 38 and, using a similarpushing motion, proceeds to enlarge the third osteotomy site 32C usingthe cutting mode.

Once the remaining two osteotomy sites 32B, 32C have been enlarged bythe second osteotome 36B, the surgeon installs the third osteotome 36Cinto the drill motor 38 and sets the rotational direction tocounter-clockwise. Again skipping the completed first osteotomy site32A, the second 32B and third 32C osteotomy sites are enlarged bycompacting. In both cases, the surgical motor 38 is set to turn in thecounter-clockwise direction and the previously expanded holes are deemedprecursor holes to the subsequent operations. The second osteotomy site32B has now been expanded as much as the surgeon desires; no furtherexpansion is needed of the second osteotomy site 32B. However, the thirdosteotomy site 32C still requires additional expansion, as the intendedimplant for the third site 32C has a larger diameter than the implant tobe placed in the second osteotomy site 32B. Therefore, the surgeoninstalls the fourth osteotome 36D into the drill motor 38 and sets therotational direction to counter-clockwise. The enlargement accomplishedby the third osteotome 36C now comprises a precursor hole for the nextoperation at the third osteotomy site 32C, with its newly enlargedentrance 33 in the exposed surface of the bone and a still closed bottom35. Skipping the completed first 32A and second 32B osteotomy sites, thethird 32C osteotomy site is further enlarged using the previouslydescribed densifying mode technique. Appropriately sized implants 34 (orfixture portions of implants) can now be installed at each osteotomysite 32A-32C. For example, the surgeon may place a 3.0-3.25 mm implant(not shown) into the first osteotomy site 32A, a 5.0 mm implant (notshown) into the second osteotomy site 32B, and a 6.0 mm implant (notshown) in the third osteotomy site 32C.

A surgeon may thus concurrently prepare a plurality of osteotomy sites32A, 32B, 32C . . . 32 n coupled with the ability to expand one site bycompacting and another site by cutting without removing the osteotome 36from the drill motor 38. The rotary osteotome 36 is thus configured tobe turned at high speed in one direction to enlarge an osteotomy bycompacting and in an opposite rotary direction to enlarge a differentosteotomy by cutting.

Turning now to FIG. 6 , an osteotome 36 according to an earlierembodiment of this invention is shown including a shank 40 and a body42. The shank 40 has an elongated cylindrical shaft that establishes alongitudinal axis of rotation A for the rotary osteotome 36. A drillmotor engaging interface 44 is formed at the distal upper end of theshaft for connection to the drill motor 38. The particular configurationof the interface 44 may vary depending on the type of drill motor 38used, and in some cases may even be merely a smooth portion of the shaftagainst which the jaws of a collet may grip. The body 42 joins to thelower end of the shank 40, which joint may be formed with a tapered ordomed transition 46. The transition 46 acts something like an umbrellaas the surgeon irrigates with water during a procedure. The gentletransition 46 facilitates the flow of irrigating fluid onto theosteotomy site while the osteotome 36 is spinning.

The body 42 preferably has conically tapered profile decreasing from amaximum diameter adjacent the shank 40 and transition 46 to a minimumdiameter adjacent an apical end 48. However, in some contemplatedembodiments the body may be non-tapered (i.e., cylindrical). The apicalend 48 is thus remote from the shank 40. The working length or effectivelength of the body 42 is proportionally related to its taper angle andto the size and number of osteotomes (36A, 36B, 36C, 36D . . . 36 n) ina kit. Preferably, all osteotomes 36 in a kit will have the same taperangle, or approximately the same taper angle, and preferably thediameter at the upper end of the body 42 for one osteotome (e.g., 36A)is approximately equal to the diameter adjacent the apical end of thebody 42 for the next larger size osteotome (e.g., 36B). Taper anglesbetween about 1° and 5° (or more) are possible depending upon theapplication. More preferably taper angles between about 2°-3° willprovide satisfactory results. And still more preferably, a taper angleof about 2°36′ is known to provide outstanding results for dentalapplications when the body 42 length is between about 11 mm and 15 mm.

The apical end 48 is defined by at least one, but preferably a pair oflips 50. The lips 50 are in fact edges that are disposed on oppositesides of the apical end 48, but in the illustrated embodiment do not liewithin a common plane. In other words, as shown in FIGS. 14 and 15 , thelips 50 may be slightly offset (in terms of a direct diametricalalignment) by the short length of a chisel point 52 extending centrallythrough the longitudinal axis A. The chisel point 52 is a common featurefound in drilling tools, but alternative apical end 48 formations to thechisel point 52 are of course possible, including rounded and simplepointed shapes, etc. As mentioned, the lips 50 are edges that angleupwardly and outwardly (radially) from the apical end 48. The angle ofthe lips 50 may be varied to optimize performance for the application.Lip 50 angles relative to the longitudinal axis A may range betweenabout 30° (very pointed) and 75° (very blunt). In the illustratedexamples, the lip angle is approximately 60° measured relative tolongitudinal axis A, or 120° measured between the two opposing lips 50.

Each lip 50 has a generally planar first trailing flank 54. The firsttrailing flanks 54 are canted from their respective lips 50 at a firstangle. The first angle may be varied between about 30° and 60° tooptimize performance for the application. In practice, the first anglemay be approximately 45° measured relative to longitudinal axis A (showncoinciding with lip face 60 in the semi-circular cross-sectional view ofFIG. 15A). It will be appreciated therefore that the two opposing firsttrailing flanks 54 are set in opposite directions so that when theosteotome 36 is rotated in use, the first trailing flanks 54 either leador follow their respective lips 50. When first trailing flanks 54 leadtheir respective lips 50, the osteotome is said to be turning in anon-cutting direction for the densifying mode; and conversely when thefirst trailing flanks 54 follow their respective lips 50, the osteotomeis said to be turning in a cutting direction where the lips 50 cut orslice bone on descent. Or said another way, the cutting direction can bedefined as rotationally sweeping the cutting faces 66 into the bone (orhost material in non-medical applications). In the densifying direction,the first trailing flanks 54 form, in effect, a large negative rakeangle for the lips 50 to minimize chip formation and shear deformationin the bone (or other host material) at the point of contact with thelips 50. (See for example FIGS. 17 and 20 .)

A generally planar second trailing flank 56 is formed adjacent to, andfalls away from, each first trailing flank 54 at a second angle. Thesecond angle is smaller than the first angle, preferably less than about55°. In an example where the first trailing flanks 54 are formed at 45°(relative to the axis A), the second trailing flanks 56 may be 40° orless. A generally planar relief pocket 58 is formed adjacent to, andfalls away from, each second trailing flank 56 at a third angle. Thethird angle is smaller than the second angle. In an example where thesecond trailing flanks 56 are formed at 40° (relative to the axis A),the relief pockets 58 (i.e., the third angle) may be 30° or less. Eachrelief pocket 58 is disposed in a sector of the apical end 48 between asecond trailing flank 56 and a lip 50. A generally axially disposed lipface 60 extends between the relief pocket 58 and the adjacent lip 50.This is perhaps best shown in the enlarged view of FIG. 10 . When theosteotome 36 is rotated in the cutting direction, a significant amountof bone chips collect in the relief pocket 58 regions. When theosteotome 36 is rotated in the densifying direction, little to no bonechips collect in the relief pocket 58 regions.

FIG. 15A is a highly simplified and exemplary semi-circularcross-section through the apical end 48 of the osteotome 36, as takenalong lines 15A-15A in FIG. 15 . In this simplified illustration, smallpoints are placed at the intersection of planar surfaces 54, 56 and 58.The node-like points do not exist in reality, but are added in this viewto help distinguish boundaries of the different surfaces (54, 56, 58,60). In combination with the several other views and descriptions, FIG.15A will help inform the skilled artisan as to the various facets (54,56, 58, 60) and their relationships to one another and to the lips 50.

A plurality of grooves or flutes 62 are disposed about the body 42. Theflutes 62 may or may not have common axial length and radial depths.I.e., it is possible that the flutes 62 could, in some configurations,not all be identical. The flutes 62 are preferably, but not necessarily,equally circumferentially arranged about the body 42. The diameter ofthe body 42 may influence the number of flutes 62. As an example, bodies42 in the range of about 1.5-2.8 mm may be formed with three or fourflutes; bodies 42 in the range of about 2.5-3.8 mm may be formed withfive or six flutes; bodies 42 in the range of about 3.5-4.8 mm may beformed with seven or eight flutes; and bodies 42 in the range of about4.5-5.8 mm may be formed with nine or ten flutes. And so on. Of course,number of flutes 62 may be varied more or less than the examples givenhere in order to optimize performance and/or to better suit theparticular application.

In the illustrated embodiment, the flutes 62 are formed with a helicaltwist. If the cutting direction is in the right-hand (clockwise)direction, then preferably the helical spiral is also in the right-handdirection. This RHS-RHC configuration is shown throughout the Figures,although it should be appreciated that a reversal of cutting directionand helical spiral direction (i.e., to LHS-LHC) could be made if desiredwith substantially equal results. The diameter of the body 42 mayinfluence the angle of the helical spiral. Typically, spirals betweenabout 5° and 20° are possible for the body 42 diameters between about1.2 mm and 6 mm. As an example, bodies 42 in the range of about 1.5-2.8mm may be formed with a 9.5° spiral; bodies 42 in the range of about2.5-3.8 mm may be formed with an 11° spiral; bodies 42 in the range ofabout 3.5-4.8 mm may be formed with a 12° spiral; and bodies 42 in therange of about 4.5-5.8 mm may be formed with a 12.5° spiral. Of course,the spiral angles may be varied more or less than the examples givenhere in order to optimize performance and/or to better suit theparticular application. Indeed, any diameter body 42 between about 1.2mm and 6 mm may be formed with a helical spiral in the general range ofabout 5° to 20°.

As perhaps best shown in FIGS. 15 and 16 , each flute 62 has adensifying face 64 and an opposing cutting face 66. A rib or land isformed between adjacent flutes 62, in alternating fashion. Thus, afour-flute 62 osteotome 36 will have four lands, a ten-flute 62osteotome 36 will have ten interleaved lands, and so forth. Each landhas an outer land face 70 that extends (circumferentially) between thedensifying face 64 of the flute 62 on one side and the cutting face 66of the flute 62 on its other side. The sharp interface between each landface 70 and its associated cutting face 66 is referred to as a workingedge 72. Depending on the rotational direction of the osteotome 36, theworking edge 72 either functions to cut bone or compact bone. That is,when the osteotome is rotated in the cutting direction, the workingedges 72 slice and excavate bone (or other host material). When theosteotome is rotated in the densifying (non-cutting) direction, theworking edges 72 compress and radially displace bone (or other hostmaterial) with little to no cutting whatsoever. This compaction andradial displacement is exhibited as gentle pushing of the osseousstructure laterally outwardly in a condensation mechanism. FIG. 15depicts a core diameter 74 superimposed as a broken circle. FIG. 35 alsolabels the core diameter 74 as the shortest perpendicular distancebetween diametrically opposing flutes 62. The core diameter 74 is theroot or central portion of the body 42 that joins all of the lands. Thediameter of the core diameter 74 varies with the tapering diameter ofthe body 42.

The working edges 72 are shown throughout the illustrations as beingsubstantially margin-less, in that the entire portion of each land face70 is cut away behind the working edge 72 to provide complete clearance.In standard prior art burs and drills, margins are commonly incorporatedbehind the working edge to help guide the drill in the hole and maintainthe drill diameter. Primary taper clearance angles, i.e., the anglebetween a tangent of the working edge 72 and each land face 70 as shownin FIG. 16 , may fall anywhere between about 1° and 35° depending uponthe application and, possibly, on the diameter of the body 42. Primarytaper clearances between about 5° and 20° have been found effective forthe body 42 diameters between about 1.2 mm and 6 mm. As an example,bodies 42 in the range of about 1.5-2.8 mm may have land faces 70 formedwith a 15° primary taper clearance; bodies 42 in the range of about2.5-3.8 mm may have land faces 70 formed with an 15° primary taperclearance; bodies 42 in the range of about 3.5-4.8 mm may have landfaces 70 formed with a 12° primary taper clearance; and bodies 42 in therange of about 4.5-5.8 mm may have land faces 70 formed with a 10°primary taper clearance. Of course, the primary taper clearance anglesmay be varied more or less than the examples given here to optimizeperformance and/or to better suit the application. As mentioned above inconnection with the angle of the helical twist, the substantiallymargin-less working edges 72 are shown, for example in FIG. 14 , turningaway from the densifying direction as the conically tapered profile ofthe body 42 decreases in diameter. In other words, when the densifyingdirection is counter-clockwise as shown in FIG. 14 , the helical twistof the working edges 72 winds in the counter-clockwise direction whenviewed from the top of the body 42 looking toward its apical end 48. Orconversely, as shown in FIG. 14 when viewed from the apical end 48looking toward top of the body 42, the twist will appear to be in theclockwise direction. Thus, when the densifying direction iscounter-clockwise, the working edges 72 will “turn away from thedensifying direction” when all of the land faces 70 and flutes 62 orbitcounter-clockwise about the longitudinal axis A as one traces each landface 70 and flute 62 downwardly toward the apical end 48.

The cutting face 66 establishes a rake angle for each respective workingedge 72. A rake is an angle of slope measured from the leading face ofthe working edge 72 to an imaginary line extending perpendicular to thesurface of the worked object (e.g., inner bone surface of theosteotomy). Rake angle is a parameter used in various cutting andmachining processes, describing the angle of the cutting face relativeto the work. Rake angles can be: positive, negative or zero. Accordingto FIG. 16 , the rake angle for working edge 72 when rotated in acutting direction may be about zero degrees (0°). In other words, thecutting face 66 in the example of FIG. 16 is oriented approximatelyperpendicular to a tangent of the arc scribed through the working edge72. As shown in FIG. 16 , this establishes a crisp cutting edge 72well-suited to cut/slice bone when the osteotome 36 is rotated in thecutting direction. However, it has been discovered that the cuttingfunctionality of the rotary osteotome 36 can be improved by changing therake angle of the cutting face 66 between about 0° and about −65°(negative rake) as a function of distance from the apical end 48. Thisoptimization of the rake angle of the cutting face 66 is described indetail below in connection with FIGS. 33-47 .

When the osteotome 36 is counter-rotated, in the densifying mode, theeffective rake angle is established between the working edge 72 and theland face 70, which as previously stated may lie at a large negativerake angle in the order of about 55°-89°, which is the compliment of theprimary taper clearance angle. The large negative rake angle of theworking edge 72 (when rotated in a densifying direction) applies outwardpressure at the point of contact between the wall of the osteotomy 32and the working edge 72 to create a compression wave ahead of the pointof contact, loosely akin to spreading butter on toast.Osseodensification may also be loosely compared to the well-knownprocess of burnishing metal to improve metal surface quality.

Downward pressure applied by the surgeon is needed to keep the workingedge 72 in contact with the bone surface of the osteotomy 32 beingexpanded. That is, pressure is needed to generate and propagate acompression wave in the bone that begins when the contact stressesexceed the yield strength of the host bone material. This is aided bythe taper effect of the osteotomy 32 and tool 36 to create lateralpressure (i.e., in the intended direction of expansion). The harder thesurgeon pushes the rotary osteotome 36 into the osteotomy 32, the morepressure is exerted laterally. This gives the surgeon complete controlof the expansion rate irrespective to a large degree on the rotationspeed of the osteotome 36, which is a factor underlying the shortlearning curve required to master the osseodensification technique.Thus, the compaction effect's intensity depends chiefly on the amount offorce exerted on the osteotome 36, which is controlled by the surgeon.The more force exerted, the quicker expansion will occur.

As each working edge 72 drags across the bone, the applied forces can bedecomposed into two components: one normal to the bone's surface,pressing it outwardly, and the other tangential, dragging it along theinner surface of the osteotomy 32. As the tangential component isincreased, the working edge 72 will start to slide along the bone. Atthe same time, the normal force will deform the softer bone material. Ifthe normal force is low, the working edges 72 will rub against the bonebut not permanently alter its surface. The rubbing action will createfriction and heat, but this can be controlled by the surgeon byaltering, on-the-fly, the rotation speed and/or pressure and/orirrigation flow. Because the body 42 of the osteotome 36 is tapered, thesurgeon may at any instant during the surgical procedure lift theworking edges 72 away from contact with the surface of the bone to allowcooling. This can be done in a controlled “bouncing” fashion wherepressure is applied in short bursts with the surgeon continuouslymonitoring progress and making fine corrections and adjustments. SeeFIGS. 7 and 8 which illustrate this variable application of force andthe ability for the osteotome to be lifted out of engagement—at any timeduring a procedure—with the walls of the osteotomy 32. As thesurgeon-applied downward force increases, eventually the stresses in thebone's surface exceed its yield strength. When this happens, the workingedges 72 will plow through the surface and create a trough behind. SeeFIG. 32 . The plowing action of the working edges 72 thus progressivelyenlarges the osteotomy until the rotary osteotome 36 reachesfull/maximum depth, at which time a different larger rotary osteotome 36must be used to achieve further expansion if desired.

FIG. 9 depicts a Stress-Strain curve that is generally illustrative forbone and other ductile materials including but not limited to foammetals and cellular polymers of the type used in various commercial,industrial and aerospace applications. The straight-line segment of thecurve from the point of origin (0,0) to B represents the material'selastic response region. Reference point B indicates the elastic limitof the material. While the elastic properties of bone are well-known, ifthe load imposed by the surgeon does not exceed the bone's ability todeform elastically, i.e., beyond point B, the bone will promptly returnto its initial (un-deformed) condition once the stress is removed. Onthe other hand, if the load imposed by the surgeon exceeds the bone'sability to deform elastically, the bone will deform and change shapepermanently by plastic deformation. In bone, the permanent change inshape may be associated with micro-cracks that allow energy release, acompromise that is a natural defense against complete fracture. If thesemicro-cracks are small, the bone remains in one piece while theosteotomy expands. The region of plastic deformation extends from theyield point of the material (C), all the way to the point of fracture(E). The peak (D) of the curve between yield point (C) and fracture (E)indicates the material's ultimate tensile strength. When a material(e.g., bone) is subjected to stress in the region between its yieldpoint (C) and its ultimate tensile strength (D), the materialexperiences strain hardening. Strain hardening, also known as workhardening or cold working, is the strengthening of a ductile material byplastic deformation. This strengthening occurs because of dislocationmovements and dislocation generation within the crystal structure of thematerial—which for bone materials corresponds with the dislocation ofthe cross-links between collagen fibers in the bone tissue. The materialtends to experience necking when subjected to stress in the regionbetween its ultimate tensile strength (D) and the point of fracture (E).

The direction of helical twist can be designed to play a role incontributing to the surgeon's control so that an optimum level of stress(in the strain hardening zone between (C) and (D) on the graph of FIG. 9) can be applied to the bone (or other host material) throughout theexpansion procedure. In particular, the RHS-RHC configuration describedabove, which represents a right-hand spiral for a right-hand cuttingdirection (or alternatively an LHS-LHC configuration, not shown) appliesa stress that provokes a beneficial opposing axial reaction force (Ry)in the host bone when the osteotome 36 is continuously rotated at highspeed in a densifying direction and concurrently forcibly advanced(manually by the surgeon) into an osteotomy 32. This opposing axialreaction force (Ry) is illustrated graphically in FIGS. 11-13 as beingdirectionally opposite to the forcibly advanced direction into theosteotomy 32. In other words, if the surgeon operating the osteotome 36is pushing the osteotome 36 downwardly into an osteotomy 32, then theopposing axial reaction force (Ry) works in the opposite direction topush the osteotome upwardly. The opposing axial reaction force (Ry) isthe vertical (or perhaps more accurately the “axial” vis-à-vis thelongitudinal axis A) component of the reaction force (R) that is theNewtonian “equal and opposite reaction force” applied by the boneagainst the full length of the working edges 72 of the osteotome 36(i.e., Newton's Third Law of Motion). An opposing axial reaction force(Ry) is also created by the effectively large negative rake angle at thelips 50 when the osteotome 36 is rotated in a densifying direction, asshown in FIG. 20 and easily perceived from FIG. 15A. Those of skill inthe art will appreciate alternative embodiments in which the opposingaxial reaction force (Ry) is created by either the configuration of thelips 50 alone or of the working edges 72 alone rather than by both (50,72) acting in concert as in the preferred embodiment.

For a surgeon to advance the apical end 48 toward the bottom of theosteotomy 32 when the osteotome 36 is spinning in the densifyingdirection, he or she must push against and overcome the opposing axialreaction forces (Ry) in addition to supplying the force needed toplastically displace/expand the bone as described above. The osteotome36 is designed so that the surgeon must continually work, as it were,against the opposing axial reaction forces (Ry) to expand the osteotomy32 by compaction, i.e., when in the densifying mode. Rather than being adetriment, the opposing axial reaction forces (Ry) are a benefit to thesurgeon by giving them greater control over the expansion process.Because of the opposing axial reaction forces (Ry), the osteotome 36will not be pulled deeper into the osteotomy 32 as might occur with astandard “up cutting” twist drill or burr that is designed to generate atractive force that tends to advance the osteotome toward the interiorof the osseous site. Up-cutting burrs have the potential to grab andpull the burr more deeply into the osteotomy, which could lead toinadvertent over-penetration.

In the densifying mode, the intensity of the opposing axial reactionforces (Ry) is always proportional to the intensity of force applied bythe surgeon in advancing the body 42 into the osteotomy 32. Thisopposing force thus creates real-time haptic feedback that is intuitiveand natural to inform the surgeon whether more or less applied force isneeded at any given instant. This concurrent tactile feedback takes fulladvantage of the surgeon's delicate sense of touch by applying reactionforces (R, and in particular the axial component Ry) directly throughthe osteotome 36. In this densifying mode, the mechanical stimulation ofthe opposing axial reaction forces (Ry) assists the surgeon to bettercontrol the expansion procedure on the basis of how the bone (or otherhost material) is reacting to the expansion procedure in real time.

Thus, the controlled “bouncing” or “pumping” action described above inconnection with FIGS. 7-9 is made more effective and substantially morecontrollable by the opposing axial reaction forces (Ry) so that thesurgeon can instinctively monitor progress and make fine corrections andapplied pressure adjustments on-the-fly without losing control over therate of expansion. The tactile feedback from the opposing axial reactionforces (Ry) allows a surgeon to intuitively exert stress on the bonematerial so that its strain response preferably resides in the strainhardening zone, that is, between its yield point (C) to its ultimatetensile strength (D). In any event, the surgeon will endeavor tomaintain the stress (as generated by the force he or she applies throughthe rotating osteotome 36) above the elastic limit (B) and below thepoint of fracture (E). Of course, until the applied stress passes theelastic limit (B), the bone will not permanently deform at all; and toapply stress beyond the point of fracture (E) will cause the bone (orother host material) to break—possibly catastrophically.

The exemplary graph in FIG. 8 plots the force applied by a surgeon toadvance the body 42 into an osteotomy 32 against its depth ofpenetration into the osteotomy 32 in three separate procedures (A-B-C)to graphically show how the surgeon can make these on-the-flyadjustments depending on particular situation they encounter. Theapplied force is, as mentioned above, the force manually generated bythe surgeon and needed to overcome the combined opposing axial reactionforces (Ry) plus the forces needed to expand/deform the bone. Theapplied force creates stress in the bone (or other host material), sothat it develops a strain response like that shown in FIG. 9 . During anoperation, the surgeon uses his or her skill to manually vary theapplied stress so that the strain response remains within the plasticdeformation region (B-E), and more preferably still within the moreideal strain hardening region (C-D). The configuration of the osteotome36, therefore, is designed to give a surgeon more control during anexpansion (densifying mode) procedure by generating proportional,opposing axial reaction forces (Ry) when the osteotome 36 continuouslyrotated and concurrently forcibly advanced into an osteotomy 32.

FIGS. 17-21 illustrate the ability of the rotary osteotome 36 tosimultaneously auto-graft and compact bone. The compaction aspect may bedefined as the gentle push of osseous structure laterally outwardly tocompact the cells throughout the region surrounding the osteotomy 32. InFIG. 17 , an osteotomy 32 formed by the present invention is shown withexaggerated taper on the order of ˜7° (as compared with the preferredtaper angle in the range of about 2°-3°) to highlight the necessarygrinding of a small amount of bone (or other host material) with eachprogressively larger osteotome 36.

In FIG. 17 , surface 76 indicates the inner wall of the osteotomy 32 asprepared in a preceding expansion operation by an osteotome 36 ofsmaller size. That is to say, in this example the surface 76 representsa precursor hole. The apical end 48 of the next incrementally largersize osteotome 36 is shown in solid about to enter the osteotomy andagain approximately ⅔ into the osteotomy 32. It is to be understood thatthe osteotome 36 is continuously rotated at high speed in a densifyingdirection (e.g., counter-clockwise) and concurrently forcibly advancedinto an osteotomy 32 by the surgeon's manual efforts. Construction line78 indicates the cylindrical (i.e., non-tapering) path of the apical end48 as it moves from top to bottom within the osteotomy 32. In otherwords, the diameter of the apical end 48 remains the same, and thereforethe diameter of its path 78 also remains constant over the distance ittravels. When the osteotome 36 first enters the osteotomy 32 as shown insolid, the internal diameter of the prior osteotomy 76 is approximatelyequal to the diameter of the apical end 48. However, the internaldiameter of the prior osteotomy 76 progressively narrows (i.e., tapersinwardly) toward the bottom 35 of the osteotomy 32. Yet as shown thecylindrical path of the apical end 48 remains constant. Therefore, asthe osteotome 36 is advanced deeper toward the bottom 35 of theosteotomy 32, more and more bone is ground away and/or displaced to makeroom for the advancing (larger) osteotome 36. Region 80, defined as theannular space between surfaces 76 and 78 (plus a portion of the apicalend 48), represents the bone material that is milled and/or displaced bythe outermost edges of the lips 50 as the apical end 48 makes its way tothe full depth of the osteotomy 32. The milled or ground region 80includes not only the side walls, but also the apical end 48 of theosteotome 32. As a reminder, the taper angle is shown substantiallyexaggerated in FIG. 17 , such that the grinding region 80 appears muchlarger than would be the case with a smaller taper angle of about 2°-3°.In a subsequent operation (not shown), when another osteotome 36 of thenext larger size is used to further expand the osteotomy 32, a similar(but larger) region 80 will exist as its apical end 48 is pushed to thebottom 35 of the osteotomy 32, and so on.

Remaining within the context of FIG. 17 , surface 82 indicates the outerwall of the osteotomy 32 as prepared by the expansion operation ofosteotome 36 when its apical end 48 reaches the bottom 35. The surface82 is a substantially perfect negative of the revolving osteotome body42. In other words, the surface 82 will have a taper equal to that ofthe osteotome body 42, and a bottom impression made by the spinningapical end 48 of the osteotome illustrated. Region 84, defined as theannular space between surfaces 78 and 82, represents the bone materialthat is plastically displaced by the working edges 72 of the lands asthe osteotome body 42 makes its way to the full depth of the osteotomy32. All of the bone material within region 84 is compacted radiallyoutwardly into the surrounding bone structure without cutting, andtherefore represents a zone of densified bone.

An important observation may be stated as: “What happens to theground/milled bone material that once occupied region 80?”. As alludedto previously, the osteotome 36 is configured to simultaneouslyauto-graft and compact the ground/milled bone from region 80 as it isrotated and forcibly advanced into the osteotomy 32. The auto-graftingphenomena supplements the basic bone compaction and condensation effectsdescribed above to further densify the inner walls 82 of the osteotomy.Furthermore, auto-grafting—which is the process of repatriating thepatient's own bone material—enhances natural healing properties in thehuman body to accelerate recovery and improve osseointegration.

Turning to FIG. 20 , an enlarged view is shown of the interface betweenthe apical end 48 and the host bone material as taken from thecircumscribed area in FIG. 17 . At the point where the outermost edge ofeach rotating and forcibly advancing lip 50 contacts the bone, attritioncauses the bone to be ground away. The bone debris collects mainly onthe second trailing flanks 56, i.e., immediately behind the respectivefirst trailing flanks 54. Some of the accumulated bone debris migratesradially inwardly along the lips 50 and is carried all the way to thevery bottom of the osteotomy 32. The remainder of the accumulated bonedebris is distributed along the flutes 62 which directly intersect thesecond trailing flanks 56 by the pressure exerted through the surgeon'smanual pushing efforts. This is illustrated in FIG. 21 . Observe that aplurality of flutes 62 open into the second trailing flanks 56. (Seealso FIG. 43 in which a plurality of flutes 162 are clearly shownmeeting with each second trailing flank 156 for receiving an up-flow ofboney slurry in densifying mode.) In the smallest diameter osteotomes36, perhaps only two flutes 62 will intersect the second trailing flanks56. However, as osteotome 36 diameter increases, the opportunity forthree or more flutes 62 to accept outflow of bone particles directlyfrom the second trailing flanks 56 becomes quite practical. These flutes62 readily carry bone debris away from the grinding interface, therebyreducing the possibility of heat- and/or pressure-induced necrosis inthe bone particles. Despite the abundant outflow capacity enabled by theplurality of flutes 62 opening into the second trailing flanks 56, it ispossible that a small fraction of bone debris could spill over into therelief pockets 58, but this is of minimal significance.

Bone debris that is distributed up the flutes 62 works its way towardthe associated land faces 70 where it is wiped and pressed into thecellular walls of the osteotomy 32 and immediately grafted back into thepatient's bone very near to the sight were it was harvested. Bone debristhat is carried to the bottom of the osteotomy 32 is wiped and pressedinto the bottom of the osteotomy 32. As a result, an auto-grafting zone86 is developed around and under the compaction region 84, as shown inFIG. 17 . Interestingly, the auto-grafting zone 86 is thinnest where thecompaction zone 84 is thickest, and conversely the auto-grafting zone 86is thickest where the compaction zone 84 is thinnest. And at theosteotomy bottom 35 where this is little-to-no compaction at all, thereis a significant zone of auto-grafting 86 which serves to densify (andpositively stimulate) an area of the osteotomy 32 which could otherwisenot be densified. This is confirmed in the micro-CT image of FIG. 22 ,far-right osteotomy. It can therefore be appreciated that theauto-grafting phenomena is an ideal complement to the basic bonecompaction and condensation effects in preparing an osteotomy 32 toreceive an implant 34 or other fixation device.

FIGS. 22-23D are micro-CT images developed in Porcine tibia. FIG. 22 isa transverse slice through a Porcine03 medial tibial plateau withcomparative holes created by three different methods. The far-leftosteotomy was created using a prior art burr drill. Note the rough,uneven side walls. The center osteotomy was created by a rotaryosteotome 36 as in FIG. 6 rotated in a cutting direction (i.e., in thecutting mode). Note the relatively clean/uniform side walls. Thefar-right osteotomy was generated by the rotary osteotome 36 of FIG. 6rotated in a counter-clockwise direction (i.e., in the densifying mode).

FIGS. 23A-D are micro-CT images developed in different types of Porcinetibia using the rotary osteotome 36 of FIG. 6 rotated in both cuttingand densifying directions. FIGS. 23A and 23C both portray axial sliceviews of Porcine03 medial tibial plateau holes. FIGS. 23B and 23D bothportray axial slice views of Porcine02 medial tibial plateau holes. InFIGS. 23A & 23B, the rotary osteotome 36 was rotated in the cuttingdirection (cutting mode). In FIGS. 23C & 23D, the rotary osteotome 36was rotated in the reverse direction (densifying mode). These images arecompared and contrasted with one another to illustrate the effects ofthe same rotary osteotome 36 rotated clockwise to accomplish cutting andcounterclockwise to accomplish osseodensification in two different bonetypes. A densification crust (buttressing layer) in the bone side wallscan be identified by the white regions surrounding the osteotomies inFIG. 22 (far-right) and FIGS. 23C and 23D.

To summarize, osseodensification is a method to preserve bone and itscollagen content to enhance its plasticity. It will allow for enlargingan osteotomy 32 by compacting (and/or by cutting when rotation isreversed) with a rotary osteotome 34 in preparation for a subsequentlyplaced implant or fixture 34. The basic steps of the method begin withthe provision of a host material, which in the preferred embodiment isbone however in other contemplated applications could either a cellularor non-cellular non-bone materials. A precursor hole 32 is also createdin the host material. This precursor hole could either be a pilot holedrilled with a relatively small diameter standard twist drill or a holeformed by previous application of the cutting or densifying techniquesof a precursor rotary osteotome. In either case, the precursor hole 32has an interior surface (i.e., sidewall 76) that extends between agenerally circular entrance 33 in an exposed surface of the hostmaterial and a bottom 35 that is closed, most commonly by the hostmaterial. The bottom 35 will have a generally conical shape as createdby the tip of the pilot drill or preceding osteotome 36. If theprecursor hole is formed by a previous application of a rotary osteotome36, then its interior surface will be tapered with a frusto-conicalshape, and with the entrance 33 having a slightly larger diameter thanthe bottom 35.

The method further includes the step of providing a rotary osteotome 36configured to be turned at high speed in either a cutting or densifyingdirection. Whether the osteotome 36 is enlarging by compacting or bycutting, it rotates at high speed as opposed to low-speedoscillating/rocking motions as taught by some prior art systems. Theosteotome 36 comprises a shank 40 and a body 42 joined to the shank 40.The body 42 has an apical end 48 remote from the shank 40, and aconically tapered profile that decreases from a maximum diameteradjacent the shank 40 to a minimum diameter adjacent the apical end 48.

The osteotome 36 is operatively connected to a surgical motor 38, withits rotation speed set somewhere between about 200-2000 RPM and itstorque setting at about 5-50 Ncm. During the procedure, copiouslyirrigation is provided in the form of a continuous stream of asubstantially incompressible liquid 102 onto the rotating body 42adjacent the entrance 33 to the precursor hole 32.

The body 42 is continuously rotated in a densifying direction while itsapical tip 48 is forcibly advanced by the surgeon into the entrance 33of the precursor hole 32. Continued advance results in an enlargement ofthe precursor hole 32 by forcibly pushing the rotating body 42 so thatits working edges 72 sweep against the interior surface of the precursorhole 32 to gently expand the bone by incremental plastic deformationsthat cause a progressive enlargement of the precursor hole 32 beginningadjacent the entrance 33 and developing in a frustoconical patterndownwardly toward the bottom 35. This enlarging step preferably includesaxially stroking or pumping the rotating body 42 within the precursorhole 32 so that the working edges 72 alternately lap against the boneinterior surface with downward motion and then separate from theinterior surface with upward motion in ever deepening movements thatcause a progressive plastic deformation of the interior surface of theprecursor hole. When the working edges 72 are in physical contact withthe bone, the surgeon can manually apply variable axial pressuredepending on the haptic sensed responsiveness of the bone. The enlargingstep also includes lapping the working edges 72 against the interiorsurface of the precursor hole 32 without the working edges 72 cuttinginto the surrounding bone, and in a manner where the rate of advancetoward the bottom 35 of the precursor hole 32 is independent of the rateof rotation of the body 42. This latter characteristic contrasts withsome prior art systems that couple tool rotation with the rate ofadvance.

Notable improvements in this present invention include: grinding aprogressively larger amount of bone material with the apical end 48 asthe body 42 is advanced deeper into the osteotomy 32, auto-grafting theground bone material into the host bone within the osteotomy 32 andcompacting the ground bone material into the host bone with the flutedbody 42, and also generating an opposing axial reaction force (Ry) inopposition to the advancing direction of the body 42 into the osteotomy32. The opposing axial reaction force (Ry) is created by theconfiguration of the lips 50 and/or the working edges 72.

After removing the osteotome 36 from the expanded hole, additionalexpansion steps can be practiced to make the hole even larger, or thefixture portion of an implant 34 or other anchoring device can beinserted into the prepared osteotomy 32. The step of installing afixture 34 or anchor would include directly engaging an exterioranchoring thread form of the fixture 34 or anchor into the expanded holethat has been formed by the working edges 72.

The tools and techniques of this invention are readily adaptable to themethods of computer generated implant placement guides, like thosedescribed for example in the Applicant's own WO 2016/187493 to Huwais,published Nov. 24, 2016 (the entire disclosure of which is herebyincorporated by reference in jurisdictions permitting incorporation byreference). According to these methods, a computer model is createdgiving jawbone 30 structural details, gum surface shape information andproposed teeth or dental prosthesis shape information. The computermodel shows the bone structure, gum surface and teeth images properlyreferenced to one another so that osteotomy 32 positions can be selectedtaking into consideration proper positioning within the bone 30 as wellas proper positioning with respect to the implant 34.

FIGS. 24-26 illustrate an alternative embodiment of this invention,namely an ultrasonic osteotome 90 configured to enlarge an osteotomywithout rotation. The ultrasonic osteotome 90 includes a shank and anadjoined body 92. The body 92 having an apical end 94 remote from theshank. The body 92 is generally smooth (i.e., non-fluted) and has aconically tapered profile decreasing from a maximum diameter adjacentthe shank to a minimum diameter adjacent the apical end 94. The overallproportion and dimensions of the body 92 will be similar to those of thebody 42 in the preceding examples. The apical end 94 includes aunidirectional grinding formation that may take the form of a roughedsurface. As the ultrasonic osteotome 90 is vibrated at a high frequency(as by a commercial off-the-shelf surgical ultrasonic generator) theapical end 94 has the effect of grinding some small portion of bone in amanner not too dissimilar from that of the apical end 48 in the earlierembodiments. The body 92 further includes an auto-grafting ramp 96configured to auto-graft and compact bone after the bone has beenultrasonically pulverized by the apical end 94 as the body is forciblyadvanced into an osteotomy concurrently with high-frequency vibration.In this example, the auto-grafting ramp 96 is a frusto-conical memberdisposed immediately below the smooth tapered portion of the body 92.The auto-grafting ramp 96 extends at a first angle that is larger thanthe taper of the body 92 so that the granular bone debris will be packedinto the surrounding walls of the osteotomy with wedge-like action.

FIGS. 27-27B are intended to illustrate, for the benefit of the skilledartisan, that the principles of this invention are not limited to dentalapplications, but any bone preparation site within the human (or animal)body may be investigated for suitability. Initial indications revealthat applications in the vertebrae and hand/wrist are prime candidatesfor osteotomies 32 formed with a rotary osteotome 36. However, thepotential range of applications is not limited to the indicated regionsin FIG. 27 , nor even to human patients.

Furthermore, as shown in FIG. 28 the principles of this invention arenot limited to bone as the host material. Indeed, the osteotome orrotary tool 36 of this invention may be configured to enlarge a hole inalmost any type of cellular or solid material by cutting and/orcompacting. (In non-medical applications, the osteotome 36 should beidentified as simply a tool or rotary tool to avoid confusion with theosteo-prefix which implies use in bone.) In this illustration, a sectionof metal foam 98 may be of the type used in aerospace, heat shieldingand other critical applications. The foam metal is shown including ahole 100 formed by compacting according to the methods described above.The resulting hole 100 is better prepared to receive a screw or otherfixation anchor because its inner sidewall has been densified by thecompressive displacement and auto-grafting effects of this invention. Inaddition to foam metals, any inorganic materials that have visco-elasticproperties similar to live bone are especially good candidates. Someexperimentation has been made as well with hole formation innon-cellular inorganic materials like plate aluminum and plastic.Certain benefits have presented as well in these non-cellular materials,such that the potential to improve screw or anchor retention by holepreparation using the principles of this invention are fullycontemplated.

Referring now to FIGS. 29-32 , an enhanced operational mode of thepresent invention will be described when combined with a continuous flowof irrigation fluid 102, such as by an external irrigation hand piece.The irrigation fluid is preferably an incompressible liquid like sterilesaline solution or water, however other suitable liquids could be usedinstead.

FIG. 29 corresponds, generally, to FIGS. 7 and 11 but with a particulardistinction—the working edges 72 of the osteotome 36 are slightlyseparated from the inner sidewall of the osteotomy 32 as occursrepeatedly while practicing the controlled “bouncing” techniquedescribed above. This separation is visible in the magnified view ofFIG. 30 . When a continuous flow of irrigating fluid 102 is provided andthe rotary osteotome 36 is rotated in the densifying mode, the reversetwist of the flutes 62 propels (pumps) the irrigation fluid 102 downtoward the bottom 35 of the osteotomy 32. That is, the flutes 62transport the irrigating fluid something akin to the axial thrust-givingelements of a screw pump or marine propeller. As a result, irrigatingfluid 102 is forcefully driven toward the bottom 35 of the precursorhole throughout the surgical procedure. This pumping or propellingaction is depicted by the downwardly twisting arrows in FIG. 29 .

Excess irrigation fluid 102 is continually pushed out of the osteotomy32 in the gap around the osteotome 36. (It will be appreciated that whenthe tool 36 is used in non-medical applications, instead of an osteotomy32 the tool 36 is placed in the entrance to a hole 100 in the surface ofa host material.) Thus, so long as the flow of irrigating fluid 102 ismaintained and the osteotome 36 is rotated inside the osteotomy 32, ahydraulic pressure is created that pushes outwardly within the osteotomy32. A generally uniform pressure gradient 104 in the irrigating fluid isillustrated by radiating arrows. When operated in the densifying mode,the pressure gradient pushes against the bone side walls at all timesduring the surgical procedure, preparing and preconditioning theinterior surface of the precursor hole prior to the enlarging step.

When the tapered osteotome 36 is held (by the surgeon) so that itsworking edges 72 are maintained in separation from the inner side wallsof the osteotomy 32, the propelled hydrating pressure created by thedownward pumping action of the flutes 62 will be generally equallydistributed across the entire inner surface of the osteotomy 32according to the general principles of hydraulics and fluid dynamics. Asthe surgeon moves the rotating osteotome 36 deeper into the osteotomy 32but still its working edges 72 do not directly contact the inner sidewalls of the osteotomy 32, as shown for example in FIGS. 29 and 30 , thehydraulic pressure will increase within the osteotomy 32. Excessirrigation fluid 102 continues to be exhausted out of the osteotomy 32but through a smaller circular gap around the osteotome 36, which leadsto the increase in hydraulic pressure.

The pressure gradient 104 will thus increase and decrease in directresponse to the amount of force applied by the surgeon as he or sherepeatedly advances and relaxes the rotating osteotome 36 into theosteotomy 32. The pressure gradient 104 will be smallest when theosteotome 36 is held far away from the side walls of the osteotomy 32;and conversely will be largest when the working edges 72 of theosteotome 36 are pushed hard into the side walls of the osteotomy 32. Bymodulating the position of the osteotome 36 in combination with acontinuous supply of irrigation fluid 102, the surgeon can apply anevenly distributed, expansive pressure with piston-like effect to theinner side walls of the osteotomy 32—without physically touching thewalls of the osteotomy 32 with the working edges 72. This throbbinghydraulic effect has many preconditioning advantages, which include: 1)gentle pre-stressing of the bone structure of the osteotomy 32 inpreparation for subsequent compacting contact, 2) haptic feedbacktransmitted through the osteotome 36 that allows the surgeon totactically discern the instantaneously applied pressure prior to actualcontact between the osteotome 36 and side walls, 3) enhanced hydrationof the bone structure which increases bone toughness and increases boneplasticity, 4) hydraulically assisted infusion of bone fragments 80 intothe lattice structure of the surrounding bone, 5) reduced heat transfer,6) hydrodynamic lubricity, 7) dampening or cushioning of the traumasensed by the patient, and so forth.

With regard to the haptic feedback advantages, the pressurizedirrigation fluid 102 will have a significant amplifying effect ascompared to an imagined scenario in which no irrigating fluid is used.In the latter hypothetical, haptic feedback is produced solely by thedirect physical contact between the bone sidewalls and the working edges72 and lips 50. When the surgeon “bounces” the osteotome in use, hapticfeedback would abruptly stop the moment there is a separation betweenthe bone sidewalls and the working edges 72 and lips 50. However, withirrigating fluid 102 the haptic feedback is augmented by reaction forcesall along the apical tip 48 as well as by the pressure gradient 104 thatsurrounds the osteotome 36 even when there is a slight separationbetween the bone sidewalls and the working edges 72 and lips 50 as inthe example of FIG. 30 .

FIG. 31 depicts, graphically, the pressure gradient 104 as exertedagainst the inner side walls of the osteotomy 32 when the surgeon bringsthe working edges 72 of the spinning osteotome 36 into direct contactwith the bone side walls. Arrows radiating normally from the side wallsof the osteotomy 32 continue to represent the pressure gradient 104.When the working edges 72 of the osteotome 36 breach the hydrodynamicbuttressing layer, they will perform the compacting action described indetail above. In the region of direct contact, the pressure gradient 104will experience a sharp increase as a result of mechanically appliedpressure through the working edges 72, which in turn causes the bonestructure to plastically deform. Meanwhile, the irrigating fluid 102trapped below the osteotome 36 will continue to apply a preconditioninghydro-static pressure below the apical tip 48 of the osteotome 36. Byaxially stroking the rotating body 42 within the precursor hole 32, thehydraulic pressure inside the precursor hole will modulate in directresponse to the surgeon's movements. And so, in practice a surgeon willrepeatedly apply and relax force on the continuously rotating osteotome36 to progressively advance the osteotome 36 deeper and deeper towardits bottom 35 until a desired final depth is reached. The hydraulicassist provided by the irrigating fluid 102 enables a much cooler,faster, smoother and controllable expansion procedure. Furthermore, thedampening effect provided by the hydraulic action of the irrigatingfluid 102 helps to cushion the patient's sensation of force applied bythe surgeon, thereby resulting in a more comfortable experience.

FIG. 32 depicts a horizontal cross-section through the osteotomy 32, astaken generally along lines 32-32 in FIG. 31 . FIG. 32 offers asnap-shot of the instantaneous pressure gradient 104 around one workingedge 72 of the osteotome 36. As can be readily see from this view, theinstantaneous pressure gradient 104 will be relatively low in the regionof the flutes 62. It may be expected that the instantaneous pressuregradient 104 in the region of the flutes 62 will be close in value tothe pressure gradient below the apical tip 48 of the osteotome 36.However, the pressure quickly increases, i.e., spikes, as the land faces70 act like wedges to quickly compress the fluid 102 in advance of theworking edges 72. The irrigating fluid 102 trapped between the landfaces 70 and the inner wall of the osteotomy 32 acts as a high-pressurecushion layer always ahead of (i.e., leading) the working edges 72, andtogether act vigorously on the bone structure of the osteotomy 32 tohelp expand its diameter and produce a buttressing layer (densificationcrust) in bone (or a hardening crust in case of metals and othernon-bone host materials). The working edges 72, which perpetually trailthe high-pressure cushion layer during rotation in the densifyingdirection, break through the cushion layer to make direct contact withthe bone side walls when enough downward force is applied by thesurgeon.

When direct bone-to-edge contact is made, the working edges 72 performthe compacting action described above to simultaneously expand theosteotomy 32 and create the densification crust (buttressing layer) inthe bone side walls. However, as soon as the surgeon lifts the osteotome36 even a little, more irrigating fluid 102 washes over thejust-burnished surface. Therefore, when the surgeon gently lifts theosteotome 36 up after having made some expansion progress, a wash ofpressurized irrigating fluid 102 immediately enhances hydration of thebone structure, gently pre-stresses the bone structure in preparationfor further compacting by the working edges 72, hydraulically infusesbone fragments 80 into the lattice structure of the surrounding bone,cools the interface, and so forth. This cycle may repeat many times asthe surgeon gently bounces the rapidly spinning osteotome 36 towardfinal depth. In many cases, the surgeon will bounce the spinningosteotome 36 into and out of contact with the bone sidewall some 5-20times before reaching the bottom 35. With each bounce, the hydraulicpressure surges just prior to direct contact to precondition theosteotomy 32 and thereby improve both performance and results.

The method of this invention therefore includes the step ofpreconditioning the interior surface of the precursor hole 32 prior tothe above-described enlarging step. The preconditioning step includesbuilding hydraulic pressure inside the precursor hole 32 between theapical tip 48 and the bottom 35 by the propelling the incompressibleliquid 102 in-between the flutes 62 of the high-speed rotating osteotome36 toward the bottom of the precursor hole 32. The hydraulic pressurecan be modulated inside the precursor hole 32 in direct and somewhatproportional response to the step of axially stroking the rotating body42 within the precursor hole 32. The preconditioning step furtherincludes generating an elevated hydrodynamic pressure surge or spikeimmediately upstream of, that is in the angular direction of rotation,of the working edge 72. The generating step further includes locatingthe pressure spike radially outwardly from the land face 70 of eachland. As shown graphically in FIG. 32 , the hydrodynamic pressure spikeis less than the mechanical pressure generated in the host material bydirect physical contact of the working edge 72, but greater than thepressure gradient in the pockets of the flutes 62.

The present invention, when operated with a continuous supply ofirrigating fluid 102, may be used to form holes in many different typesof materials in addition to bone. For examples, malleable metals (e.g.,aluminum) or plastics may be used at the host material. The irrigatingfluid in these circumstances may be an oil or cutting-fluid substancerather than water or saline. When the non-bone host material iscellular, like in the case of foam metals and polymers, the hostmaterial may behave somewhat like bone. However, when the host materialin not cellular but rather solid, displaced stock will have a tendencyto mound above and below the hole rather than being auto-grafted intothe sidewalls of the hole 100. This mounding represents malleablematerial that is plastically displaced by the compression wave of theworking edge 72, and further enhanced overall by the aforementionedhydraulic assistance. As a result, the effective stock thickness arounda hole formed in non-cellular material will be substantially greaterthan the original stock thickness.

Accordingly, the present invention may be used in non-medicalapplications as a tool and method of hole formation characterized byhydrodynamic compacting. Advantages and benefits of hydrodynamiccompacting include low plastic deformation due to rolling and slidingcontact with rotating tool 36. Hydrodynamic compacting occurs with atool 36 that has working edges 72 to densify the side walls of the holeas it is formed. Lubrication/irrigation is provided to eliminateoverheating and to create a viscose hydrodynamic layer of densification,among many other advantages. Hydrodynamic compacting occurs when theload is well controlled beneath the ultimate strength. Hydrodynamiccompacting occurs where a large negative rake angle (non-cutting edge)is used as a compacting edge. While regular twist drills or straightfluted drills have 2-3 lands to guide them through the hole,hydrodynamic compacting drills preferably have 4 or more lands andflutes.

Those of skill in the art will appreciate that the osteotome of thisinvention could be configured with a straight or non-tapered body ratherthan the tapered working end as shown in the illustrations. Accordingly,the described osteotomy enlargement techniques can be accomplished usingnon-tapered tools via the novel method of compacting in combination withhydrodynamic effects.

Referring now to FIGS. 33-47 , a modified and enhanced rotary osteotomeis generally indicated at 136. Throughout FIGS. 33-47 , referencenumbers introduced above but offset by 100 are used to identify like orcorresponding features. Thus, the rotary osteotome 136 compares to therotary osteotome 36 of FIGS. 5-21 and 29-32 , and shares many similarfeatures therewith. In fact, the enhanced rotary osteotome 136 and theprevious rotary osteotome 36 are substantially identical in mostrespects save the shaping of their flutes 162, 62, respectively. Theflutes 162 of the enhanced rotary osteotome 136 are specially shaped toachieve an outcome not possible with the earlier rotary osteotome 36,namely a moderate degree of densification when operated in the cuttingmode. The rotary osteotome 36 of FIGS. 5-21 and 29-32 was not capable ofproducing a buttressing layer when operated in the cutting mode, as canbe discerned by the micro-CT images in FIG. 22 (center) and FIGS. 23Aand 23B. However, the modified geometry of the flutes 162 enable theenhanced rotary osteotome 136 to produce a partially densified crustwhen rotated in the cutting direction. See FIG. 38 . The early stagebuttressing layer produced in cutting mode by the enhanced rotaryosteotome 136 is less developed than when the same enhanced rotaryosteotome 136 is operated in the densifying mode. Nevertheless, thisability to achieve some degree of densification in cutting mode canprove useful to the surgeon in many applications, such as hard bone toname one. And, if desired, the buttressing layer can be further enhancedby performing a novel densify-after-cut (DAC) protocol which will bedescribed below.

FIG. 33 is a side elevation of the enhanced rotary osteotome 136. Thebody 142 of the rotary osteotome 136 includes a stopper section 106 thatextends between the terminus of the flutes 162 and the transition 146.The stopper section 106 produces a vital plugging action to prevent thecontinued migration of bone particles along the flutes 162 in cuttingmode, and thereby self-arrest the cutting performance of the osteotome136 when operated in the cutting direction. FIG. 34 , which is across-section taken helically along 34-34 in FIG. 33 , reveals twodiametrically-opposing flutes 162. The flutes 162 of the enhanced rotaryosteotome 136 are shaped to progressively decrease in size (i.e.,cross-sectional area) from the apical end 48.

In practice, it has been found that the axial length of the stoppersection 106 should be at least equal to, and preferably greater than,the average width of the flutes 162. That is, if the average width ofthe flutes 162, as measured along their full helical length, is 1.8 mmfor example, then the axial length of the stopper section 106 should beat least 1.8 mm, for example. In practice, for dental applications, thestopper section will be greater than or equal to about 2 mm, assuggested in FIG. 42 . For larger orthopedic applications, the flutes162 may be larger and thus the stopper section 106 may likewise betaller to achieve the desired plugging action.

Some of the relevant features of the flutes 162 are expressly called outin the cross-sectional FIG. 35 . Here, the core diameter 174 is labeled,which corresponds to the depth of the flutes 162 along the length of thebody 142. The rake angle is also labeled along one cutting face 166.Also labeled is a heel side angle, which corresponds to the approximateangle of the densifying faces 164 of each flute 162. The relief anglebehind each working edge 172 is shown, along with the land width for oneof the land faces 170. These diagrams are provided to facilitatecomprehension of the following descriptions of the augmented flute 162geometries which characterize the enhanced rotary osteotome 136.

In the enhanced design, the rake angles (i.e., the angular relationshipbetween each cutting face 166 and a radial passing through thecorresponding working edge 172) have been changed to negative (like aburnishing tool) along substantially their entire length. (Onealternative embodiment mentioned below describes a variation in whichthe lower leading portion of each flute has an aggressive zero or evenpositive rake but transforms to a negative rake approximately mid-body.)The rake angle of the initially-described rotary osteotome 36 waspreferably established at zero along the entire length of the flutes 62.See FIG. 16 . Although the negative rake angles of the enhanced rotaryosteotome 136 can vary widely, grinds between about −1° and −75° (i.e.,negative like for a burnishing tool) can enable the new and previouslyunanticipated advantages of this embodiment while still producingsatisfactory cutting results. The stated range can be improved,somewhat, by maintaining the negative rake angles between about −5° and−65°. Even better cutting results can be achieved by setting the rakeangles between about −5° and −50°. And in some cases superior resultshave been achieved when the rake angles are between about −10° and −40°.

The same or generally the same negative rake angle may be maintainedalong the entire length of the flute 162. For example, in the images ofFIGS. 43-46 , the rake angle remains in a relatively tight range ofabout −13° to −28° (˜15° variance) along the lengths of the flutes 162.Specifically, the rake angles are measured at about −28°/−18°/−13°/−24°for FIGS. 43-46 , respectively. Fluctuations like this may, in someinstances, be mandated by manufacturing constraints. The negative rakeangle can be intentionally designed to change along the length of theflutes 162 rather than being held to a tolerance. The change can berelatively small (e.g., <30° variance) or relatively large (e.g., >30°variance). Intentional changes in the rake angle can be fluctuating (asseen to a small degree in FIGS. 43-46 ), regressive or progressive. Aprogressive change would indicate that the rake angle is at its smallest(closest to zero) adjacent the apical end 148 and grows smoothly to amaximum adjacent the stopper section 106. A progressive change innegative rake is illustrated in FIG. 36 . A regressive change, on theother hand, would mean the negative rake angle is larger at the apicalend 148 and grows smaller (and thus more aggressive in cutting mode)near the stopper section 106.

FIG. 36 portrays one half of the cross-sectional body portion 142 inexaggerated detail to emphasize a progressive change in the negativerake angle, as well as a progressive decrease in depth of the flutes162. Several exemplary profiles from the one visible,helically-sectioned flute 162 appear above the cross-sectioned flute162, with construction lines extending the rake angles for clarity.Notably, the rake angle near the apical end 148 is between about −5° and−10°. However, the rake angles become progressively more negative towardthe stopper section 106. Near the terminus of the flute 162, the rakeangle is about −60° or −65° which causes the working edge 172 to behavemore like a compaction edge than a cutting edge when rotating in thecutting mode.

Like the rake angles, the heel-side angles can either remain generallyconstant (i.e., within a tolerance) along the full length of the flutes162 or change. FIGS. 36 and 43-46 illustrate examples where theheel-side angles of the densifying faces 164 vary along the length ofthe flutes 162 with a total variance of less than 30°. When measuringthe heel-side angle against a radial passing through the point ofintersection between the densifying face 164 and its associated landsurface 170 (as in FIG. 35 ), the heel-side angles are seen in FIG. 36to be smallest adjacent the apical end 148, and largest adjacent thestopper section 106. In FIGS. 43-46 , the heel-side angles are about39°/42°/44°/65°, respectively. Thus, the absolute values of both theheel-side angles and rake angles may be designed to increase from aminimum adjacent the apical end 148 to a maximum adjacent the stoppersection 106.

Good results have been realized when the heel-side angles are betweenabout 15° and 55°. Even better results can be achieved by setting theheel-side angles between about 15° and 40°. And in some cases superiorresults have been achieved when the heel-side angles are between about15° and 35°.

Considering the primary relief angle (also referend to as a primarytaper clearance, e.g., in FIG. 16 ) good results have been observed whenthe angle is between about 6° and 34°. Even better results can beachieved by setting the primary relief angles between about 6° and 28°.And in some cases superior results have been achieved when the primaryrelief angles are between about 10° and 25°.

FIG. 36 is also notable for the wedge-like construction lines passingthrough the working edges (on the high side) and the base of the fluteprofiles (on the low side). These construction lines visually reinforcea feature of this exemplary embodiment where the depth of the flutes 162intentionally changes along the length. The change in FIG. 36 isregressive, meaning that the flute 162 depth is a maximum nearest theapical end 148, and becomes smaller as it approaches the stopper section106. Another way to describe this change in flute 162 configurationwould be to consider the cross-sectional area of the flute at each pointalong its length. Again, with reference to the exemplary profiles inFIG. 36 , the area of the flutes 162 can be seen to be smallest adjacentthe stopper section 106 and largest adjacent the apical end 148. Theregressive change in flute 162 depth and cross-sectional area, as shownin FIG. 36 , can be combined with rake angles that are constant, thatfluctuate (FIGS. 43-46 ), that are progressive (FIG. 36 ) or regressive.Likewise, regressive change in flute 162 depth and/or area can becombined with heel-side angles that are constant, fluctuating,progressive or regressive. It is believed that a regressive change influte 162 depth and/or area combined with at least some negative rakeangle is a relevant contributing factor to the advantageous cutting-modecharacteristics of the enhanced rotary osteotome 136.

For embodiments in which the negative rake angle changes progressively,as in FIG. 36 , satisfactory results can be obtained when the rakeangles start at about 0° to −30° adjacent the apical end 148 andprogress to about −45° to −70° adjacent the stopper section 106. Reliefangles may be formed in the range of about 5° to 35°. And heel-sideangles may be formed in the range of about 15° to 55°. However, itshould be clearly understood that the progressive or regressive changein any of these attributes of the flutes 162 is not a requirement toachieve the stated advantages of the enhanced rotary osteotome 136. Forexample, the embodiment of FIGS. 43-46 offers a viable alternative whoserake angle is neither singularly progressive nor regressive.

When the enhanced rotary osteotome 136 is used in the cutting mode, boneparticles quickly fill the flutes 162. FIGS. 37-38 depict an enhancedrotary osteotome 136 being operated in the cutting mode. Although notshown here, continuous external irrigation accompanies the procedure asin the earlier examples. In FIG. 37 , the enhanced rotary osteotome 136is descending into an osteotomy 132 in cutting mode. Bone particles areseen filling the flutes 162. Mixed with blood and collagen andirrigating fluid, the bone chips have the consistency of a semi-viscousslurry. In FIG. 38 , the enhanced rotary osteotome 136 has reached itsintended depth at the bottom 135 of the osteotomy 132. Observe in FIG.38 that once the entire lengths of the flutes 162 have entered theosteotomy 132, there is no convenient egress for the bone particleslurry from the flutes 162. The stopper section 106 seals or traps thebone particles between the flutes 162 and the sidewalls of the osteotomy132 like a cork or piston. If the surgeon continues to advance therotating osteotome 136 deeper into the osteotomy 132, substantialresistance will be encountered. The trapped bone chip slurry will becomepressurized inside the flutes 162 in response to the force of thesurgeon's push. Hydraulic pressure is indicated by the tiny outwardlydirected arrows in FIG. 38 . The hydraulic pressure can be pulsatedthrough the bone particle slurry, if the surgeon wishes, by theaforementioned pumping action.

FIG. 40 represents an enlarged, fragmentary cross-sectional view takengenerally mid-length of the body 142. In this figure, a single flute 162is shown with entrapped bone particles after the stopper section 106 hasdescended fully into the osteotomy 132 (as in FIG. 38 ). The enhancedrotary osteotome 136 in this illustration is being rotated in thecutting direction. The negative rake angle presented by the cutting face166 is evident. Outwardly directed arrows indicate hydraulic pressure inthe semi-viscous bone particle slurry caused, chiefly, by the continuedadvance of the enhanced rotary osteotome 136 after the flutes 162 havefully submerged in the osteotomy. Continued pressure causes more andmore bone particles to be packed into the confined flutes 162.

FIG. 41 is a highly-magnified view of the area circumscribed at 41 inFIG. 40 to show the cutting face 166 and working edge 172. Because ofthe high pressure generated in the semi-viscous bone particle slurry,combined with the negative rake angle at the cutting face 166, theenhanced rotary osteotome 136 operating in cutting mode begins to forcethe slurry into the surrounding wall surfaces of the osteotomy 132,thereby beginning to form an incipient densification crust. That is tosay, the enhanced rotary osteotome 136 with negative rake angle flutes162 will increase to the point of producing an outward stain thatactually separates the working edge 172 from contact with the osteotome132 and stops the cutting action. Some of the bone particles andcollagen are autografted directly back into the sidewalls of theosteotomy 132 when operating in the cutting mode. As a result, anysubsequently installed implant or fixture to be screwed into theosteotomy 132 (i.e., hole in the case of non-medical applications) willbenefit with heightened initial stability.

Moreover, the enhanced rotary osteotome 136 enables a novel new protocolwhich may be referred to as Densify-After-Cut (DAC). The DAC protocol iswell-suited to hard bone conditions, in which the same enhanced rotaryosteotome 136 is used to cut then densify again within the sameosteotomy 132 in a single continuous operation. In an exemplary casepresenting in very dense bone, a surgeon may either first begin toenlarge the osteotomy 132 in cutting mode, or perhaps may begin withdensifying mode but quickly switch to cutting mode after encounteringstrong resistance. Regardless, the enhanced rotary osteotome 136 isadvanced into the osteotomy 132 until reaching the desired depth incutting mode, presumably due to the hard bone conditions making use ofdensifying mode ill-advised. Due to cutting mode action, the flutes 162will have accumulated bone particle slurry as depicted in FIG. 38 . Oncethe terminus of the flutes 162 at the stopper section 106 has descendedinside the osteotomy 132, the early stages of autografting andcondensation will begin, as described above. The osteotomy 132 is nowenlarged and the surgeon may withdraw the enhanced rotary osteotome 136and either place an implant or enlarge the osteotomy 132 further with alarger osteotome 136. Alternatively, the surgeon may instead invest afew additional seconds to apply the DAC protocol. The DAC protocolincludes the following added steps. Without removing the body 142 of theenhanced rotary osteotome 136 from the osteotomy 132, the surgeonchanges the drill motor to reverse (densifying mode), still set at highspeed rotation, and uses centrifugal force together with the heel sideflute 162 profiles and the tapered shape of the body 142 to auto-graftall of the remaining entrapped bone particles and collagen back into theosteotomy walls. Copious external irrigation continues throughout theprocedure. A gentle pumping action, i.e., axial stroking of the spinningbody 142 inside the osteotomy 132, is recommended so that the apical end148 makes intermittent contact with the osteotomy bottom 135. Thisgentle pumping action in high-speed reverse rotation will facilitate aneven formation of a full or nearly full buttressing layer (i.e.,densification crust) like that seen in FIGS. 22 (far-right), 23C and23D. By not removing the body 142 of the enhanced rotary osteotome 136from the osteotomy 132 before switching to a densifying mode ofoperation, the surgeon re-deposits (auto-grafts) the cut bone particlesand collagen inside the host osteotomy 132.

The general steps of the DAC protocol are outlined in FIG. 39 in theform of a simplified flow diagram. In reference to that figure, thesurgeon initially determines an intended depth of the osteotomy 132.This depth will have been earlier established with a pilot drilling stepand possibly one or more preceding expansion steps using, preferably butnot necessarily, enhanced rotary osteotomes 136 of smaller diameter(s).Considering the last expansion step only prior to placement of animplant (34, not shown), the surgeon installs an enhanced rotaryosteotome 136 in his or her drill motor (38, not shown). Irrigation ofthe osteotomy site is expected to take place continuously throughout theprocedure. The surgeon may or may not initiate the final expansionprocedure in the cutting mode. Knowing that the densifying mode producesa superior densification crust, and the surgeon may initiate the finalexpansion procedure in densifying mode but switch to cutting mode afterencountering too much resistance. Regardless of which mode is used tostart the final expansion step, the surgeon completes the finalexpansion step in cutting mode. In cutting mode, as described above,chips and blood and collagen and irrigating fluid accumulate as a boneyslurry in the flutes 162. Advance of the enhanced rotary osteotome 136is discontinued when the apical end 148 reaches the depth limitpredetermined by the surgeon. Without removing the enhanced rotaryosteotome 136 from osteotomy 132, the surgeon reverses rotationaldirection of tool inside osteotomy 132. The semi-viscous bone chipslurry captured in the flutes 162 is transferred into the surroundingsidewalls of the osteotomy 132 by the high-speed reverse-rotating body142. Accompanied with a gentle up and down pumping motion, the workingedges 172 autograft the boney slurry directly into the osteotomy 132walls while concurrently forming a densified crust. After only a fewseconds in densifying mode, e.g., about 3-10 seconds, the surgeonwithdraws the body 142 from the enlarged osteotomy 132 and proceeds withthe next phase of the procedure. The DAC protocol represents anefficient method to enlarge an osteotomy 132 in hard bone using theenhanced rotary osteotome 136, while preserving (autografting)substantially all of the cut bone and collagen back into the sidewalls.

FIG. 42 depicts the body 142 of the enhanced rotary osteotome 136according to one exemplary embodiment of the invention. FIG. 43 is anapical end view and FIGS. 44-47 represent lateral cross-sections takenat various elevations: 4 mm, 8 mm, 13 mm and ˜15 mm, respectively, asmeasured from the apical end 148. In FIGS. 44-46 , the cross-sectionsreveal the changing profiles of the flutes 162 at increasing distancesfrom the apical end 148. Comparison of the changing inclination of thecutting faces 166 in FIGS. 43-46 will reveal the aforementionedconsistently negative rake along the length of each flute 162. The endview of FIG. 43 shows the rake angles at the flutes 162 where theyintersect the second trailing flanks 156 and relief pockets 158. In FIG.43 , the rake angle is least cutter-like at the points where the flutes162 open into the respective second trailing flanks 156 and reliefpockets 158. In this embodiment where the rake angle of the cuttingfaces 166 is never positive, these openings to the flutes 162 from theapical end 148 represent the most negative rake along the entire flute162 length. The heel-side angle is at its minimum here at the apical end148. Progressing next to FIG. 44 which reveals the flute 162 profiles at4 mm from the apical end 148, the rake angles are slightly less negativeand the core diameter is larger. The depth and area of the flutecross-section is slightly smaller here. The heel-side angle is showngrowing also, meanwhile the land width remains generally unchanged.Moving on to FIG. 45 , where the flute 162 profiles are shown at 8 mmfrom the apical end 148, the rake angles are slightly less negative andthe core diameter is larger still, which coincides with a furtherreduction in the depth and area of the flute cross-section. Theheel-side angle is slightly larger and the land width remains generallyunchanged. In FIG. 46 , where the flute 162 profiles are exposed at 13mm from the apical end 148, very near their terminus at the stoppersection 106, the rake angle is increased in the negative direction andthe flutes 162 are quite shallow and small in cross-sectional area. Theheel-side angle is at its maximum as well, and the land width is shownabruptly flaring to meet the nearby stopper section 106. FIG. 47 istaken through the stopper section 106, where no flutes 162 are visible.

In summarizing the novel attributes of the enhanced rotary osteotome136, it is important to be reminded that live bone has visco-elasticproperties. When subjected to a moderate strain, i.e., within thestraight-line segment of the curve from the point of origin (0,0) to Bas shown in FIG. 9 , the bone will exhibit a generally elastic response.Continued strain beyond this point will induce a plastic deformation.The advantageous densification crust is optimally formed when anexpansion-oriented (i.e., radially outward) strain is imposed on thesidewalls of the osteotomy 132 within the strain hardening range ofB-to-D in FIG. 9 . By trapping semi-viscous bone particles and collagenand blood within the flutes 162 during the cutting mode, the enhancedrotary osteotome 136 provokes a hydraulic pressure build-up that acts inconjunction with the working edges 172 to outwardly deform theside-walls of the osteotomy 132, as illustrated in FIGS. 38 and 40 . Thepressure build-up provokes an outwardly elastic response (at leastinitially) that has the effect of decreasing contact pressure at theworking edge 72 (FIG. 41 ). Cutting action is retarded or perhaps evenarrested altogether. This, in combination with the negative rake angles(FIG. 43 ) enables the enhanced rotary osteotome 136 to transition fromcutting mode to autografting/densifying mode with continued high-speedrotation in the cutting direction as soon as the stopper section 106plugs the osteotomy 132. Hydraulic pressure is generated by thepiston-like effects of the stopper section 106, in combination withimpeller-like attributes of the negative rake angles which produceoutward force vectors. This hydraulic pressure is exerted through thebone particle slurry against the visco-elastic bone walls of theosteotomy 132. Even though the osteotome 136 is rotating at high speedin the cutting mode, further cutting action is retarded because, withsufficient pressure build-up, the side-walls of the osteotomy 132 arepushed out of direct contact with the working edge 72 as illustrated inFIG. 41 . The continued strain imposed by the pressurized boney slurryonto the side walls of the osteotomy 132 will eventually exceed thepoint of elastic deformation (B in FIG. 9 ) and induce a plasticdeformation in the ideal strain hardening region identified as C-to-D inFIG. 9 . As a result, the modified enhanced rotary osteotome 136 iscapable of producing a clean, semi-condensed osteotomy 132 when operatedin cutting mode alone. Optionally, the densification crust can then befurther intensified by applying the DAC protocol.

In another contemplated embodiment, not illustrated, the flutes 162 areconfigured to achieve both cutting and densification when operated inthe cutting mode. In particular, the rake angle could be establishednear the apical end for maximum-aggressive cutting in the cutting mode,such as with a zero or near-zero inclination angle as in FIG. 16 .However, the rake angle in this alternative embodiment would rapidlytransition to negative rake. The progression to negative rake would beso aggressive that the upper portion of the flutes would begin toapproach a negative rake angle equal with the primary taperclearance/relief angle so that the working edge 172 actually shifts tothe other side (heel-side) of the land face 170. As a result, the upperportion of the flutes would behave as compactors even though they arerotating in the cutting direction. Although the helical twist would notbe working against auto-grafting to some degree, the overall benefitsmay be substantial in some applications. A rotary osteotome of thisconfiguration would never be run backwards; it would always be operatedin cutting mode. For some surgical applications (and perhaps someindustrial applications also), the ability to rapidly form an osteotomy(hole) with densified crust by drilling in only the cutting directioncould make this option very attractive.

Referring now to FIG. 48 , yet another embodiment of the presentinvention will be described with a similar aim to rapidly form anosteotomy (or hole) with a densified crust by drilling only in thecutting direction. In this example, the body portion of the rotaryosteotome 236 is provided with two distinct fluted sections—a lowercutting section 208 and an upper densifying section 210. The flutes ofthe lower cutting section 208 have a right hand helical twist to cutwhen the osteotome 236 is turned at high speed in the cutting mode(clockwise) direction. This is consistent with the RHS-RHC configurationshown throughout the preceding Figures. Conversely, the flutes of theupper densifying section 210 have a left hand helical twist to optimallycompact when the osteotome 236 is turned at high speed in the cuttingmode (clockwise) direction. The flutes of the upper densifying section210 have a left-hand twist configuration. An annular transition zone 212may be formed in-between the cutting 208 and compacting 210 sections.

According to this embodiment, when the rotary osteotome 236 is turned athigh speed in the cutting direction and advanced into an osteotomy,semi-viscous bone particle slurry will readily flow up the flutes of thecutting section 208 and collect in the transition zone 212. The boneyslurry then migrates from the transition zone 212 into the flutes of thecompacting section 210 where they are auto-grafted into the inner wallsof the osteotomy in the densifying mode manner described above. Thetransition zone 212 acts as a pre-compaction staging area or manifoldwhere the slurry can accumulate and then find generally equalizeddistribution paths up the several flutes of the upper densifying section210. The transition zone 212 also helpfully avoids the necessity for theflutes of the lower cutting section 208 to align with the flutes of theupper densifying section 210. Also, the transition zone 212 contemplatesthat the body portion of the osteotome 236 could be made in multipleparts which are assembled in a subsequent manufacturing operation. Forexample, the lower cutting section 208 could be made as a loose piece ina dedicated manufacturing operation. And likewise, the upper densifyingsection 210 could also be made in a dedicated manufacturing operation.The lower cutting 208 and upper densifying 210 sections could then beattached, such as by any suitable joining technique. The shank could beformed integral with the upper densifying section 210 or as yet anotherloose piece that is likewise joined to the composite body section.Dissimilar materials are an option in this event. For example, the lowercutting section 208 and shank could be fabricated from surgical toolsteel, whereas the upper densifying section 210 is made from a suitablehigh-density medical grade polymer. Many options exist.

Notwithstanding, it is contemplated that the transition zone 212 isoptional, such that the flutes of the lower cutting section 208 may pairin direct alignment with the flutes of the upper densifying section 210.In this latter arrangement, bone particles migrating up each flute ofthe lower cutting section 208 will proceed directly into a correspondingflute of the upper densifying section 210 for deposition into the sidewall of the osteotomy in the manner described above. An advantage of thealternative embodiment of FIG. 48 is that the osteotomy can beprepared—both cut and densify—with a continuous forward cutting actionthereby saving time and simplifying the procedure.

It bears reiterating that all embodiments of the present invention,including those described in connection with FIGS. 33-48 , may be usedin non-medical applications for metals and foams and other non-organicmaterials. In such instances, the osteotome 36, 136, 236 is re-named asa tool or rotary tool as the term osteotome implies specifically use inbone. And indeed, all references to bone and boney slurries can beeasily reimagined by those of skill in the art as the relevant inorganicmaterial serving as host for the hole being enlarged. Also, although inthe illustrated embodiments the body 42, 142 is tapered, the novelattributes and spirit of this invention may be accomplished within thecontext of a non-tapered (i.e., cylindrical) body.

The foregoing invention has been described in accordance with therelevant legal standards, thus the description is exemplary rather thanlimiting in nature. Variations and modifications to the disclosedembodiment may become apparent to those skilled in the art and fallwithin the scope of the invention.

What is claimed is:
 1. A method for enlarging a hole in a host materialin preparation to receive a screw-in fixture, said method comprising thesteps of: having available a rotary tool configured to be turned at highspeed in a cutting direction, the tool comprising a shank and a bodyjoined to the shank, the body having an apical end remote from theshank, a plurality of flutes disposed about the body, the flutes havinga helical twist, each flute having a densifying face and an opposingcutting face, a stopper section of the body disposed between the flutesand the shank, a plurality of lands, each land formed between twoadjacent flutes, each land having a land face joining a densifying faceof one flute and a cutting face of the other flute, each land faceintersecting the respective the cutting face along a working edge,irrigating a precursor hole in a host material, the precursor holehaving an interior surface extending between a generally circularentrance and a bottom closed by the host material, rotating the body ofthe tool in a cutting direction greater than about 200 RPM, the cuttingdirection defined as rotationally sweeping the cutting faces into thehost material, enlarging the precursor hole by forcibly pushing therotating body to the bottom of the precursor hole so that the workingedges cut the host material and a slurry of host material particlesmixed with irrigating liquid accumulates in the flutes, wherein theimprovement comprises: said step of enlarging the precursor holeincluding concurrently plugging the hole with the stopper section of thebody while continuing to apply axial force to pressurize the slurrythereby autografting at least some of the host material particlesaccumulated in the flutes into the side walls of the hole.
 2. The methodof claim 1, further including the step of reversing the rotationaldirection of the rotary tool without removing the body from hole, andutilizing centrifugal force to deposit substantially all of the hostmaterial particles in the flutes into the side walls of the hole.
 3. Themethod of claim 2, wherein said reversing step includes concurrent axialpumping of the rotary tool within the hole.
 4. The method of claim 3wherein the interior surface of the precursor hole has a conicallytapered sidewall extending between the entrance and the bottom, andwherein the entrance has a larger diameter than the bottom, and the bodyof the tool is conically tapered.
 5. The method of claim 4 wherein theworking edge of each land has a helical twist that turns away from thedensifying direction as the conically tapered profile decreases indiameter.
 6. A method for enlarging a hole in a host material inpreparation to receive a screw-in fixture using a rotary osteotomeoperable in a cutting direction and a reverse densifying direction, saidmethod comprising the steps of: having available a rotary osteotomeconfigured to be turned about a longitudinal axis thereof at high speedin a cutting direction and a reverse densifying direction, the rotaryosteotome comprising a shank and a body joined to the shank, the bodyhaving an apical end remote from the shank, a plurality of flutesdisposed about the body, the flutes having a helical twist, each flutehaving a densifying face and an opposing cutting face, each cutting facedefining a rake angle and each densifying face defining a heel-sideangle, for each densifying face the associated heel-side angle is apositive angle measured in the cutting direction, for each cutting faceat least a portion of the associated rake angle is a negative rake anglemeasured in the cutting direction, a stopper section of the bodydisposed between the flutes and the shank, a plurality of lands, eachland formed between two adjacent flutes, each land having a land facejoining a densifying face of one flute and a cutting face of the otherflute, each land face intersecting the respective the cutting face alonga working edge, irrigating a precursor hole in bone, the precursor holehaving an interior surface extending between a generally circularentrance and a bottom closed by the bone, rotating the body of theosteotome in the cutting direction greater than about 200 RPM, thecutting direction defined as rotationally sweeping the cutting facesinto the bone, enlarging the precursor hole by forcibly pushing therotating body to the bottom of the precursor hole so that the workingedges cut the bone and a slurry of bone particles mixed with irrigatingliquid accumulates in the flutes, said step of enlarging the precursorhole including concurrently plugging the hole with the stopper sectionof the body while continuing to apply axial force to pressurize theslurry thereby autografting at least some of the bone particlesaccumulated in the flutes into the side walls of the hole.
 7. The methodof claim 6, further including the step of reverse rotating the rotaryosteotome at high speed in the densifying direction without removing thebody from hole, and utilizing centrifugal force to deposit substantiallyall of the bone particles in the flutes into the side walls of the hole.8. The method of claim 7, wherein said reverse rotating step includesconcurrent axial pumping of the rotary osteotome within the hole.
 9. Themethod of claim 8 wherein the interior surface of the precursor hole hasa conically tapered sidewall extending between the entrance and thebottom, and wherein the entrance has a larger diameter than the bottom,and the body of the rotary osteotome is conically tapered.
 10. Themethod of claim 9 wherein the working edge of each land has a helicaltwist that turns away from the densifying direction as the conicallytapered profile decreases in diameter.
 11. A method for enlarging a holein a host material in preparation to receive a screw-in fixture using arotary osteotome operable in a cutting direction and a reversedensifying direction, said method comprising the steps of: havingavailable a rotary osteotome configured to be turned about alongitudinal axis thereof at high speed in a cutting direction and areverse densifying direction, the rotary osteotome comprising a shankand a body joined to the shank, the body having an apical end remotefrom the shank, a plurality of flutes disposed about the body, theflutes having a helical twist and a regressive depth measuring deepestadjacent the apical end and shallowest adjacent the stopper section,each flute having a densifying face and an opposing cutting face, eachcutting face defining a rake angle and each densifying face defining aheel-side angle, for each densifying face the associated heel-side angleis a positive angle measured in the cutting direction, for each cuttingface at least a portion of the associated rake angle is a negative rakeangle measured in the cutting direction, the negative rake angle changesalong the length of each flute in a progressive manner, a stoppersection of the body disposed between the flutes and the shank, aplurality of lands, each land formed between two adjacent flutes, eachland having a land face joining a densifying face of one flute and acutting face of the other flute, each land face intersecting therespective the cutting face along a working edge, irrigating a precursorhole in bone, the precursor hole having an interior surface extendingbetween a generally circular entrance and a bottom closed by the bone,rotating the body of the osteotome in the cutting direction greater thanabout 200 RPM, the cutting direction defined as rotationally sweepingthe cutting faces into the bone, enlarging the precursor hole byforcibly pushing the rotating body to the bottom of the precursor holeso that the working edges cut the bone and a slurry of bone particlesmixed with irrigating liquid accumulates in the flutes, said step ofenlarging the precursor hole including concurrently plugging the holewith the stopper section of the body while continuing to apply axialforce to pressurize the slurry thereby autografting at least some of thebone particles accumulated in the flutes into the side walls of thehole.
 12. The method of claim 11, further including the step of reverserotating the rotary osteotome at high speed in the densifying directionwithout removing the body from hole, and utilizing centrifugal force todeposit substantially all of the bone particles in the flutes into theside walls of the hole.
 13. The method of claim 12, wherein said reverserotating step includes concurrent axial pumping of the rotary osteotomewithin the hole.
 14. The method of claim 13 wherein the interior surfaceof the precursor hole has a conically tapered sidewall extending betweenthe entrance and the bottom, and wherein the entrance has a largerdiameter than the bottom, and the body of the rotary osteotome isconically tapered.
 15. The method of claim 14 wherein the working edgeof each land has a helical twist that turns away from the densifyingdirection as the conically tapered profile decreases in diameter.